Provider Demographics
NPI:1942822911
Name:BOLLING, JACOB RYAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:RYAN
Last Name:BOLLING
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34666
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-0624
Mailing Address - Country:US
Mailing Address - Phone:508-755-2466
Mailing Address - Fax:508-755-6883
Practice Address - Street 1:95 VERNON ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-1988
Practice Address - Country:US
Practice Address - Phone:508-755-2466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPDF2545213E00000X, 213E00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program