Provider Demographics
NPI:1912555749
Name:BOLINGBROKE, JANNA MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:JANNA
Middle Name:MARIE
Last Name:BOLINGBROKE
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 1:1760 E PECOS RD STE 344
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-3208
Mailing Address - Country:US
Mailing Address - Phone:602-403-1676
Mailing Address - Fax:
Practice Address - Street 1:1760 E PECOS RD STE 344
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-3208
Practice Address - Country:US
Practice Address - Phone:602-403-1676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-223981041C0700X
UT4995004-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical