Provider Demographics
NPI:1215789276
Name:BOLTON, JEREMY VINCENT (PHD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:VINCENT
Last Name:BOLTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-4819
Mailing Address - Country:US
Mailing Address - Phone:805-354-6000
Mailing Address - Fax:
Practice Address - Street 1:1550 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-4819
Practice Address - Country:US
Practice Address - Phone:805-354-6035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA122557103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical