Provider Demographics
NPI:1700402716
Name:JOLLY, CANDACE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
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 1:2203 FOLSOM LN
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-7627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2203 FOLSOM LN
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27560-7627
Practice Address - Country:US
Practice Address - Phone:704-472-0621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health