Provider Demographics
NPI:1356402648
Name:JOLLEY, DONNA M (LCSW)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:JOLLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4200
Mailing Address - Country:US
Mailing Address - Phone:608-785-0001
Mailing Address - Fax:608-785-0002
Practice Address - Street 1:1321 N MAIN ST
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-1156
Practice Address - Country:US
Practice Address - Phone:608-637-7052
Practice Address - Fax:608-637-8500
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3616-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39082186305OtherUNITY HEALTH INSURANCE
WI39693200Medicaid
MNHP66985OtherHEALTHPARTNERS
MN13G85JOOtherBCBS-MN
WI000084003Medicare PIN
WI001084003Medicare PIN