Provider Demographics
NPI:1770041667
Name:JOLLY, MIKAELA LUGENE (CF-SLP)
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:LUGENE
Last Name:JOLLY
Suffix:
Gender:F
Credentials:CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2265 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-4516
Mailing Address - Country:US
Mailing Address - Phone:909-767-1029
Mailing Address - Fax:
Practice Address - Street 1:1490 N CLAREMONT BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-3519
Practice Address - Country:US
Practice Address - Phone:909-626-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-09
Last Update Date:2019-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist