1386695765 NPI number — MRS. ANITA GALE JOLLY MA LLPC NCC

Table of content: MRS. ANITA GALE JOLLY MA LLPC NCC (NPI 1386695765)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386695765 NPI number — MRS. ANITA GALE JOLLY MA LLPC NCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOLLY
Provider First Name:
ANITA
Provider Middle Name:
GALE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA LLPC NCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SAMPSON
Provider Other First Name:
ANITA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1386695765
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2273 SCOTT ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH BRANCH
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-664-6502
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
441 CLAY STREET
Provider Second Line Business Practice Location Address:
CHRISTIAN FAMILY SERVICES OF LAPEER COUNTY
Provider Business Practice Location Address City Name:
LAPEER
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-664-4557
Provider Business Practice Location Address Fax Number:
810-664-5181
Provider Enumeration Date:
05/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  6401008841 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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