Provider Demographics
NPI:1265163323
Name:BOLGER, JENNA (FNP)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:BOLGER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4202 E CACTUS RD APT 8306
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-7669
Mailing Address - Country:US
Mailing Address - Phone:814-381-4662
Mailing Address - Fax:
Practice Address - Street 1:5757 W THUNDERBIRD RD STE W212
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-5607
Practice Address - Country:US
Practice Address - Phone:602-603-2275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2022-09-21
Deactivation Date:2022-08-02
Deactivation Code:
Reactivation Date:2022-09-21
Provider Licenses
StateLicense IDTaxonomies
AZF06220820207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine