Provider Demographics
NPI:1982233250
Name:BOLENBAUGH, JENESSA
Entity Type:Individual
Prefix:
First Name:JENESSA
Middle Name:
Last Name:BOLENBAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 HILLCREST PARK DR STE 102
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7684
Mailing Address - Country:US
Mailing Address - Phone:541-773-7409
Mailing Address - Fax:
Practice Address - Street 1:3250 HILLCREST PARK DR STE 102
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7684
Practice Address - Country:US
Practice Address - Phone:541-773-7409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-07
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10196768237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist