Provider Demographics
NPI:1487223806
Name:BOLES, JESSE E (OD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:E
Last Name:BOLES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 HIGHTOWER CT
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7043
Mailing Address - Country:US
Mailing Address - Phone:270-314-2157
Mailing Address - Fax:
Practice Address - Street 1:952 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-4943
Practice Address - Country:US
Practice Address - Phone:270-781-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2236DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist