Healthcare Provider Details

I. General information

NPI: 1073291902
Provider Name (Legal Business Name): CLARISSA ROSALEE JOLLY TCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3640 CANTERBURY CT
WATERLOO IA
50702-5705
US

IV. Provider business mailing address

3640 CANTERBURY CT
WATERLOO IA
50702-5705
US

V. Phone/Fax

Practice location:
  • Phone: 319-252-4631
  • Fax: 319-209-9287
Mailing address:
  • Phone: 319-252-4631
  • Fax: 319-209-9287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number23055
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: