1538685730 NPI number — AMY V JOLLY LCMHC

Table of content: AMY V JOLLY LCMHC (NPI 1538685730)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538685730 NPI number — AMY V JOLLY LCMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOLLY
Provider First Name:
AMY
Provider Middle Name:
V
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCMHC
Provider Gender Code:
F

Provider's Other Name Information

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

NPI Number Information

NPI Number:
1538685730
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
530 LOCUST COVE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28752-7871
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-230-3854
Provider Business Mailing Address Fax Number:
828-724-7757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5623 US 221 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28752-7028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-437-3000
Provider Business Practice Location Address Fax Number:
828-437-4999
Provider Enumeration Date:
08/18/2017

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: 101YM0800X , with the licence number:  13158 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: A13158 . This is a "LICENSURE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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