Provider Demographics
NPI:1922586072
Name:BOLANOS, JERALYN E (LCSW)
Entity Type:Individual
Prefix:
First Name:JERALYN
Middle Name:E
Last Name:BOLANOS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11050 ARTESIA BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-2542
Mailing Address - Country:US
Mailing Address - Phone:562-860-8838
Mailing Address - Fax:562-860-0248
Practice Address - Street 1:11050 ARTESIA BLVD STE F
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-2542
Practice Address - Country:US
Practice Address - Phone:562-860-8838
Practice Address - Fax:562-860-0248
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA97310101YM0800X
CAACSW97310104100000X, 1041C0700X
CALCSW1187201041C0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program