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General NPI Number Information
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NPI Number | 1093008443
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Entity Type | Individual
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Provider Name | JESSICA LINDSAY BOLAND LCSW
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Gender | Female
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Dates
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Enumeration Date | 05/18/2011
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Last Update Date | 09/16/2021
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Provider Practice Location Address
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Address Line | 2001 S CALIFORNIA AVE STE 100
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City | CHICAGO
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State | IL
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Zip | 60608-2486
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Country | US
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Telephone | 773-916-4437
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Fax | 773-376-8847
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Provider Business Mailing Address
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Address Line | 1910 N DRAKE AVE APT 1B
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City | CHICAGO
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State | IL
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Zip | 60647-7630
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Country | US
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Telephone | 248-342-5644
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Fax | 248-342-5644
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149015771
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License Number State | IL
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