Provider Demographics
NPI:1447945563
Name:BOLYARD, JENNIFER L
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:BOLYARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 MILAN RD
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-7800
Mailing Address - Country:US
Mailing Address - Phone:419-627-8878
Mailing Address - Fax:
Practice Address - Street 1:5500 MILAN RD
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-7800
Practice Address - Country:US
Practice Address - Phone:419-627-8878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOP5932SC156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician