Provider Demographics
NPI:1598321721
Name:JEANNETTE BOLTE, PH.D, PLLC
Entity Type:Organization
Organization Name:JEANNETTE BOLTE, PH.D, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLTE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:288-596-5407
Mailing Address - Street 1:8933C LORRAINE RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4176
Mailing Address - Country:US
Mailing Address - Phone:228-897-7730
Mailing Address - Fax:228-575-0886
Practice Address - Street 1:8933C LORRAINE RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4176
Practice Address - Country:US
Practice Address - Phone:228-897-7730
Practice Address - Fax:228-575-0886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-13
Last Update Date:2021-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03501391Medicaid