Provider Demographics
NPI:1780907402
Name:BOLEN, JACK AARON (COTA)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:AARON
Last Name:BOLEN
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:RADFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24141-2430
Mailing Address - Country:US
Mailing Address - Phone:540-633-6533
Mailing Address - Fax:
Practice Address - Street 1:700 RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-2430
Practice Address - Country:US
Practice Address - Phone:540-633-6533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000124224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant