Provider Demographics
NPI:1497278311
Name:BOLDT, JONATHAN (LPCC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:BOLDT
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 EL MOLINO BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-2915
Mailing Address - Country:US
Mailing Address - Phone:575-449-2288
Mailing Address - Fax:575-267-6228
Practice Address - Street 1:350 EL MOLINO BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2915
Practice Address - Country:US
Practice Address - Phone:575-449-2288
Practice Address - Fax:575-267-6228
Is Sole Proprietor?:No
Enumeration Date:2017-07-23
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0208221101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health