Provider Demographics
NPI:1497394977
Name:BOLTZ, JACQUELINE ELIZABETH (LCSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ELIZABETH
Last Name:BOLTZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:ELIZABETH
Other - Last Name:POTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSWA
Mailing Address - Street 1:3385 SE FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3053
Mailing Address - Country:US
Mailing Address - Phone:720-563-1321
Mailing Address - Fax:
Practice Address - Street 1:5200 S MACADAM AVE STE 460
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3836
Practice Address - Country:US
Practice Address - Phone:503-912-4930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-31
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL114791041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical