Provider Demographics
NPI:1144243882
Name:HOFFMANN, JOLIE M (PSYD)
Entity Type:Individual
Prefix:
First Name:JOLIE
Middle Name:M
Last Name:HOFFMANN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2451
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-2451
Mailing Address - Country:US
Mailing Address - Phone:309-268-2172
Mailing Address - Fax:309-268-3649
Practice Address - Street 1:403 W VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3666
Practice Address - Country:US
Practice Address - Phone:309-268-2910
Practice Address - Fax:309-268-2913
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
05732028OtherBLUE CROSS BLUE SHIELD
L95216Medicare ID - Type Unspecified
05732028OtherBLUE CROSS BLUE SHIELD
IL202823Medicare ID - Type UnspecifiedMEDICARE GROUP