Provider Demographics
NPI:1639125446
Name:LEBOLT, JONATHAN (PHD, LCSW, CGP)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:LEBOLT
Suffix:
Gender:M
Credentials:PHD, LCSW, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 CERONE CT
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-4113
Mailing Address - Country:US
Mailing Address - Phone:973-524-4917
Mailing Address - Fax:
Practice Address - Street 1:38 CERONE CT
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-4113
Practice Address - Country:US
Practice Address - Phone:973-524-4917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD206181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical