Provider Demographics
NPI:1497717748
Name:BOLLYKY, JENNIFER BEART (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BEART
Last Name:BOLLYKY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:BEART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:300 PASTEUR DR
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-2200
Mailing Address - Country:US
Mailing Address - Phone:650-723-4000
Mailing Address - Fax:
Practice Address - Street 1:300 PASTEUR DR
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2200
Practice Address - Country:US
Practice Address - Phone:650-723-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC55872207R00000X
WAMD00044340207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3536BOOtherREGENCE BLUESHIELD RIDER
WA8415879Medicaid
WA0192575OtherL & I WORKERS COMP
WAP00188398OtherRAILROAD MEDICARE
WAI25545Medicare UPIN
WA3536BOOtherREGENCE BLUESHIELD RIDER