Provider Demographics
NPI:1770369894
Name:BOLDEN, JASMINE LOUVENIA
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:LOUVENIA
Last Name:BOLDEN
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 1:6460 CENTERVILLE BUSINESS PKWY
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2633
Mailing Address - Country:US
Mailing Address - Phone:937-443-7937
Mailing Address - Fax:
Practice Address - Street 1:6460 CENTERVILLE BUSINESS PKWY
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-2633
Practice Address - Country:US
Practice Address - Phone:937-265-8151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician