Provider Demographics
NPI:1629501333
Name:BOLT, JACQUELINE (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:BOLT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 N ZANG BLVD APT 718
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75203-1233
Mailing Address - Country:US
Mailing Address - Phone:253-468-3007
Mailing Address - Fax:
Practice Address - Street 1:7601 PRESTON RD
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-3214
Practice Address - Country:US
Practice Address - Phone:469-303-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS5563207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine