Provider Demographics
NPI:1700279601
Name:BOLIN, JEFFREY TYLER (MS, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:TYLER
Last Name:BOLIN
Suffix:
Gender:M
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2785 CASON ST # 2
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2843
Mailing Address - Country:US
Mailing Address - Phone:765-446-4185
Mailing Address - Fax:765-448-1864
Practice Address - Street 1:2614 CHARLESTOWN RD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-2529
Practice Address - Country:US
Practice Address - Phone:930-204-2414
Practice Address - Fax:765-448-1864
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-17
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY163604103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1-15-18435OtherBCBA CERTIFICATE