Provider Demographics
NPI:1093008443
Name:BOLAND, JESSICA LINDSAY (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:LINDSAY
Last Name:BOLAND
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1910 N DRAKE AVE
Mailing Address - Street 2:APT 1B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-7630
Mailing Address - Country:US
Mailing Address - Phone:248-342-5644
Mailing Address - Fax:248-342-5644
Practice Address - Street 1:2001 S CALIFORNIA AVE STE 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-2486
Practice Address - Country:US
Practice Address - Phone:773-916-4437
Practice Address - Fax:773-376-8847
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
IL1490157711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker