Provider Demographics
NPI:1013692516
Name:JOLLY, CAMDEN REECE
Entity Type:Individual
Prefix:
First Name:CAMDEN
Middle Name:REECE
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 1:912 PIN OAK PL
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-8539
Mailing Address - Country:US
Mailing Address - Phone:678-620-9156
Mailing Address - Fax:
Practice Address - Street 1:1715 FRIENDSHIP CIR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30028-6917
Practice Address - Country:US
Practice Address - Phone:770-240-0163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA23-280238106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician