Provider Demographics
NPI:1356717730
Name:JOLLY, JENNIFER SUE (PHD, LMHC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUE
Last Name:JOLLY
Suffix:
Gender:F
Credentials:PHD, LMHC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:SUE
Other - Last Name:LIVINGSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LMHC
Mailing Address - Street 1:113 N JOHN WAYNE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WINTERSET
Mailing Address - State:IA
Mailing Address - Zip Code:50273
Mailing Address - Country:US
Mailing Address - Phone:515-462-5967
Mailing Address - Fax:
Practice Address - Street 1:113 N JOHN WAYNE DRIVE
Practice Address - Street 2:
Practice Address - City:WINTERSET
Practice Address - State:IA
Practice Address - Zip Code:50273
Practice Address - Country:US
Practice Address - Phone:515-462-5967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA077526101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1265812440Medicaid
IA1033589049Medicaid