Provider Demographics
NPI:1225757834
Name:JOLLY, ONCHELLE ARCHELEN
Entity Type:Individual
Prefix:
First Name:ONCHELLE
Middle Name:ARCHELEN
Last Name:JOLLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3524 SW 19TH ST
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34974-5424
Mailing Address - Country:US
Mailing Address - Phone:561-983-0649
Mailing Address - Fax:
Practice Address - Street 1:1532 SW MAPP RD
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-2446
Practice Address - Country:US
Practice Address - Phone:772-678-6704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-253899106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116792000Medicaid