Provider Demographics
NPI:1023262425
Name:BOLSTER, JACQUELINE MOOD (RPT)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MOOD
Last Name:BOLSTER
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 DAMON DR
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452-2924
Mailing Address - Country:US
Mailing Address - Phone:802-878-8352
Mailing Address - Fax:
Practice Address - Street 1:11 KILBURN ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-8705
Practice Address - Country:US
Practice Address - Phone:802-878-8352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0002009225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist