Provider Demographics
NPI:1619303922
Name:RILEY-BOLDEN, JESSICA (MA, LPC)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:RILEY-BOLDEN
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 E 37TH ST STE 209
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-6210
Mailing Address - Country:US
Mailing Address - Phone:432-664-2261
Mailing Address - Fax:
Practice Address - Street 1:1901 E 37TH ST STE 209
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-6210
Practice Address - Country:US
Practice Address - Phone:432-664-2261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68702101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional