Provider Demographics
NPI:1417663485
Name:BOLTON, JESSICA LYNN (APN CPNP-PC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:BOLTON
Suffix:
Gender:F
Credentials:APN CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11092 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:GREEN VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61534-9352
Mailing Address - Country:US
Mailing Address - Phone:217-491-2274
Mailing Address - Fax:
Practice Address - Street 1:5230 6TH STREET FRONTAGE RD E
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5128
Practice Address - Country:US
Practice Address - Phone:217-585-1180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019756363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics