Provider Demographics
NPI:1457669079
Name:BOLTON, JESSICA (LAPC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BOLTON
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 FRONTIER RD
Mailing Address - Street 2:
Mailing Address - City:SHARPSBURG
Mailing Address - State:GA
Mailing Address - Zip Code:30277-1569
Mailing Address - Country:US
Mailing Address - Phone:678-459-8788
Mailing Address - Fax:
Practice Address - Street 1:756 WOODBURY HWY
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:GA
Practice Address - Zip Code:30222-1514
Practice Address - Country:US
Practice Address - Phone:706-775-0544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC003769101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional