Provider Demographics
NPI:1376294488
Name:JOLLY, JORDAN JEFFREY (LCPC)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:JEFFREY
Last Name:JOLLY
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 BROKEN TOP LN APT 212
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-3252
Mailing Address - Country:US
Mailing Address - Phone:815-419-7204
Mailing Address - Fax:
Practice Address - Street 1:634 EDDY AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59812-1802
Practice Address - Country:US
Practice Address - Phone:406-243-4712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT51413101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional