Provider Demographics
NPI:1790481497
Name:TOLLIVER, JENNIE
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:TOLLIVER
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 1:992 W IDAHO AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-2111
Mailing Address - Country:US
Mailing Address - Phone:208-741-3336
Mailing Address - Fax:
Practice Address - Street 1:992 W IDAHO AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2111
Practice Address - Country:US
Practice Address - Phone:208-741-3336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health