Provider Demographics
NPI:1417103169
Name:BOLEN, JENNIFER DIANE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DIANE
Last Name:BOLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 JENSEN AVE
Mailing Address - Street 2:
Mailing Address - City:SANGER
Mailing Address - State:CA
Mailing Address - Zip Code:93657-2251
Mailing Address - Country:US
Mailing Address - Phone:559-875-3023
Mailing Address - Fax:
Practice Address - Street 1:2511 JENSEN AVE
Practice Address - Street 2:
Practice Address - City:SANGER
Practice Address - State:CA
Practice Address - Zip Code:93657-2251
Practice Address - Country:US
Practice Address - Phone:559-875-3023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-13
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53385106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist