Provider Demographics
NPI:1639720550
Name:BOLEN, JENNIFER CHISM (FNP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CHISM
Last Name:BOLEN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5482 MS-15
Mailing Address - Street 2:
Mailing Address - City:ECRU
Mailing Address - State:MS
Mailing Address - Zip Code:38841
Mailing Address - Country:US
Mailing Address - Phone:662-488-8799
Mailing Address - Fax:
Practice Address - Street 1:5482 MS-15
Practice Address - Street 2:
Practice Address - City:ECRU
Practice Address - State:MS
Practice Address - Zip Code:38841
Practice Address - Country:US
Practice Address - Phone:662-488-8799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSF08191029363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily