Provider Demographics
NPI:1073291902
Name:JOLLY, CLARISSA ROSALEE (TCADC)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:ROSALEE
Last Name:JOLLY
Suffix:
Gender:F
Credentials:TCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3640 CANTERBURY CT
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5705
Mailing Address - Country:US
Mailing Address - Phone:319-252-4631
Mailing Address - Fax:319-209-9287
Practice Address - Street 1:3640 CANTERBURY CT
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5705
Practice Address - Country:US
Practice Address - Phone:319-252-4631
Practice Address - Fax:319-209-9287
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA23055101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)