Provider Demographics
NPI:1942317185
Name:JOLLY, JACQUELINE
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
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 1:2628 EUCLID HEIGHTS BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44106-2811
Mailing Address - Country:US
Mailing Address - Phone:216-321-3408
Mailing Address - Fax:216-321-3408
Practice Address - Street 1:3642 AVALON RD
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44120-5207
Practice Address - Country:US
Practice Address - Phone:216-561-0190
Practice Address - Fax:216-321-3408
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5838103T00000X
CA18845103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist