Provider Demographics
NPI:1265658561
Name:BOLES, JENNY LOU (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:LOU
Last Name:BOLES
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 E QUARTZ ROCK RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-0653
Mailing Address - Country:US
Mailing Address - Phone:623-434-1558
Mailing Address - Fax:
Practice Address - Street 1:1910 E SOUTHERN AVE STE 107
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-7592
Practice Address - Country:US
Practice Address - Phone:480-969-5613
Practice Address - Fax:480-844-0622
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN065960363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZS55987Medicare UPIN
AZ23066Medicare ID - Type UnspecifiedNURSE PRACTITIONER