Provider Demographics
NPI:1376885897
Name:BOLAND, JACQUELYN (NNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:
Last Name:BOLAND
Suffix:
Gender:F
Credentials:NNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 DEER HORN DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT ROYAL
Mailing Address - State:NJ
Mailing Address - Zip Code:08061-1089
Mailing Address - Country:US
Mailing Address - Phone:571-439-5119
Mailing Address - Fax:
Practice Address - Street 1:34TH STREET & CIVIC CENTER BOULEVARD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-590-3084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-22
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP012733363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal