Provider Demographics
NPI:1538240809
Name:BOLTON, JENNIFER THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:THOMAS
Last Name:BOLTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 TOWNCENTER BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TUSCALOUSA
Mailing Address - State:AL
Mailing Address - Zip Code:35406
Mailing Address - Country:US
Mailing Address - Phone:205-366-9996
Mailing Address - Fax:205-366-9971
Practice Address - Street 1:100 TOWNCENTER BLVD
Practice Address - Street 2:STE 201
Practice Address - City:TUSCALOUSA
Practice Address - State:AL
Practice Address - Zip Code:35406
Practice Address - Country:US
Practice Address - Phone:205-366-9996
Practice Address - Fax:205-366-9971
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19005207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000019004Medicaid
34837OtherBLUE CROSS
AL000019005Medicaid
ALG02962Medicare UPIN
AL000019004Medicaid
AL000019005Medicaid