MEDICARE: CLARISSA ROSALEE JOLLY TCADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	23055	IA

General Provider Information

NPI Number	:	1073291902
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARISSA ROSALEE JOLLY TCADC

Provider Business Mailing Address
First Line	:	3640 CANTERBURY CT
Second Line	:
City	:	WATERLOO
State	:	IA
Zip	:	50702-5705
Country	:	US
Telephone Number	:	319-252-4631
Fax Number	:	319-209-9287

Provider Business Practice Location Address
First Line	:	3640 CANTERBURY CT
Second Line	:
City	:	WATERLOO
State	:	IA
Zip	:	50702-5705
Country	:	US
Telephone Number	:	319-252-4631
Fax Number	:	319-209-9287

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2023
Last Update Date	:	07/10/2023

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