Basic Information
| Provider Information | |||||||||
| NPI: | 1790960953 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLAN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 HIGH ST FL 4 | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450116078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134541460 | ||||||||
| FaxNumber: | 5138633053 | ||||||||
| Practice Location | |||||||||
| Address1: | 903 NW WASHINGTON BLVD STE A | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450136367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134541111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2008 | ||||||||
| LastUpdateDate: | 08/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 35.098053 | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 0054909 | 05 | OH | MEDICAID |