Provider Demographics
NPI:1649830647
Name:BOLDEN, JEREMY CRAIG (MSW)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:CRAIG
Last Name:BOLDEN
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6049 MERLOT LN SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98513-2243
Mailing Address - Country:US
Mailing Address - Phone:253-335-0607
Mailing Address - Fax:
Practice Address - Street 1:4804 LACEY BLVD SE STE A
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5733
Practice Address - Country:US
Practice Address - Phone:360-799-5782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC609703021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical