Provider Demographics
NPI:1689338501
Name:TOLLEY, JORDAN ELICE
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:ELICE
Last Name:TOLLEY
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 1:651 W WARREN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4036
Mailing Address - Country:US
Mailing Address - Phone:321-999-6405
Mailing Address - Fax:
Practice Address - Street 1:651 W WARREN AVE STE 100
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4036
Practice Address - Country:US
Practice Address - Phone:321-999-6405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor