Provider Demographics
NPI:1295038347
Name:BOLAM, JENNIFER LEIGHT (COTA/L)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGHT
Last Name:BOLAM
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 GLYNN SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2832
Mailing Address - Country:US
Mailing Address - Phone:757-206-6347
Mailing Address - Fax:
Practice Address - Street 1:915 GLYNN SPRINGS DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2832
Practice Address - Country:US
Practice Address - Phone:757-206-6347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000679224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant