Provider Demographics
NPI:1801387667
Name:BOLDEN, JEREMY (ATC,LAT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:BOLDEN
Suffix:
Gender:M
Credentials:ATC,LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3449 BLUEWATER DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ELM
Mailing Address - State:TX
Mailing Address - Zip Code:75068-3425
Mailing Address - Country:US
Mailing Address - Phone:337-316-1948
Mailing Address - Fax:
Practice Address - Street 1:3449 BLUEWATER DR
Practice Address - Street 2:
Practice Address - City:LITTLE ELM
Practice Address - State:TX
Practice Address - Zip Code:75068-3425
Practice Address - Country:US
Practice Address - Phone:337-316-1948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-28
Last Update Date:2018-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT51652255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer