Provider Demographics
NPI:1356497101
Name:BOLDS, JACKIE A
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:A
Last Name:BOLDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10285
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6066 CIVIC TERRACE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560
Practice Address - Country:US
Practice Address - Phone:510-505-1600
Practice Address - Fax:510-494-7240
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57227261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA035074Medicare UPIN