Basic Information
| Provider Information | |||||||||
| NPI: | 1922586072 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLANOS | ||||||||
| FirstName: | JERALYN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | ACSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11050 ARTESIA BLVD STE F | ||||||||
| Address2: | |||||||||
| City: | CERRITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907032542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628608838 | ||||||||
| FaxNumber: | 5628600248 | ||||||||
| Practice Location | |||||||||
| Address1: | 11050 ARTESIA BLVD STE F | ||||||||
| Address2: | |||||||||
| City: | CERRITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907032542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628608838 | ||||||||
| FaxNumber: | 5628600248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2018 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | 97310 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.