Basic Information
| Provider Information | |||||||||
| NPI: | 1518292481 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLTEN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROBERTSON | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 33900 HARPER AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480354258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5863502644 | ||||||||
| FaxNumber: | 5865413735 | ||||||||
| Practice Location | |||||||||
| Address1: | 30100 TELEGRAPH RD STE 140 | ||||||||
| Address2: | |||||||||
| City: | BINGHAM FARMS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483850030 | ||||||||
| FaxNumber: | 2488499980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2009 | ||||||||
| LastUpdateDate: | 09/05/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 22004907A | IN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.