Provider Demographics
NPI:1760054027
Name:BOLSTAD, JORDAN (MED, LPCC)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BOLSTAD
Suffix:
Gender:F
Credentials:MED, LPCC
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:LYNN
Other - Last Name:SALWEI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, LPCC
Mailing Address - Street 1:116 ASH AVE NW STE 2
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-1367
Mailing Address - Country:US
Mailing Address - Phone:218-632-4300
Mailing Address - Fax:188-849-4151
Practice Address - Street 1:116 ASH AVE NW STE 2
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1367
Practice Address - Country:US
Practice Address - Phone:218-632-4300
Practice Address - Fax:188-849-4151
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MNCC03366101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health