MEDICARE: MRS. DEBRA K. JOLLY LPC

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	101YP2500X	Professional Counselor	180-005432	IL
2	101YP2500X	Professional Counselor	0701004469	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9932273	OTHER	IL	BLUE CROSS BLUE SHEILD

General Provider Information

NPI Number	:	1922117720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DEBRA K. JOLLY LPC

Provider Business Mailing Address
First Line	:	1833 MONUMENT DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-8772
Country	:	US
Telephone Number	:	815-272-0175
Fax Number	:

Provider Business Practice Location Address
First Line	:	638 INDEPENDENCE PKWY STE 240
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23320-5222
Country	:	US
Telephone Number	:	757-277-4213
Fax Number	:

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

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	02/19/2019

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