Provider Demographics
NPI:1720759160
Name:JOLIVETTE, RODERICK BERNARD JR
Entity Type:Individual
Prefix:MR
First Name:RODERICK
Middle Name:BERNARD
Last Name:JOLIVETTE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6645 WOODROW AVE APT A
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1765
Mailing Address - Country:US
Mailing Address - Phone:229-881-9152
Mailing Address - Fax:
Practice Address - Street 1:137 JOHNSON FERRY RD STE 2170
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-4948
Practice Address - Country:US
Practice Address - Phone:855-543-2002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA222115603545Medicaid