Provider Demographics
NPI:1134217532
Name:BOLEK, JEFFREY E (PHD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:E
Last Name:BOLEK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21403 CHAGRIN BLVD
Mailing Address - Street 2:RM 212
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5322
Mailing Address - Country:US
Mailing Address - Phone:216-346-5673
Mailing Address - Fax:
Practice Address - Street 1:21403 CHAGRIN BLVD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5322
Practice Address - Country:US
Practice Address - Phone:216-346-5673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3496103T00000X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2057116Medicaid
OH2057116Medicaid
OHBOCP79371Medicare PIN