Provider Demographics
NPI:1750300109
Name:GILLIS, JOLIE LYNN (LMHC)
Entity Type:Individual
Prefix:
First Name:JOLIE
Middle Name:LYNN
Last Name:GILLIS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:JOLIE
Other - Middle Name:LYNN
Other - Last Name:SKIPPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:525 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-5412
Mailing Address - Country:US
Mailing Address - Phone:850-522-4485
Mailing Address - Fax:850-522-4484
Practice Address - Street 1:4094 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-5648
Practice Address - Country:US
Practice Address - Phone:850-522-4485
Practice Address - Fax:850-522-4484
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7615426 00Medicaid