Provider Demographics
NPI:1316029952
Name:BRISTOW, JOLENE (RN, LPC)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:
Last Name:BRISTOW
Suffix:
Gender:F
Credentials:RN, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 W PINON DR
Mailing Address - Street 2:
Mailing Address - City:GREEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85614-4332
Mailing Address - Country:US
Mailing Address - Phone:520-370-2363
Mailing Address - Fax:
Practice Address - Street 1:701 N. LA CANADA DRIVE
Practice Address - Street 2:SUITE 90
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614
Practice Address - Country:US
Practice Address - Phone:520-625-3835
Practice Address - Fax:520-625-5585
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC 12398101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health