Provider Demographics
NPI:1174996284
Name:BOLTON, JESSI NICOLE (MA,)
Entity type:Individual
Prefix:MS
First Name:JESSI
Middle Name:NICOLE
Last Name:BOLTON
Suffix:
Gender:F
Credentials:MA,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 HUDSON LN
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-6035
Mailing Address - Country:US
Mailing Address - Phone:318-322-6500
Mailing Address - Fax:318-322-5118
Practice Address - Street 1:1300 HUDSON LN
Practice Address - Street 2:STE 10
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-6066
Practice Address - Country:US
Practice Address - Phone:318-322-6500
Practice Address - Fax:318-322-5118
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-11
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5683101YP2500X
LA1221106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist