Provider Demographics
NPI:1689115008
Name:SCOTT, JENNIFER BOLES (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BOLES
Last Name:SCOTT
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 1:688 BARCLAY LN
Mailing Address - Street 2:
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008-1011
Mailing Address - Country:US
Mailing Address - Phone:610-550-9642
Mailing Address - Fax:
Practice Address - Street 1:225 E. CHICAGO AVE.
Practice Address - Street 2:ANN & ROBERT H. LURIE CHILDRENS HOSPITAL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-227-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-17
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036.152099208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program