Healthcare Provider Details

I. General information

NPI: 1639369507
Provider Name (Legal Business Name): MAKETA JOLLY REGISTERED PSYCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2007
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 FLINT DR
NORTH EAST MD
21901-3746
US

IV. Provider business mailing address

71 FLINT DR
NORTH EAST MD
21901-3746
US

V. Phone/Fax

Practice location:
  • Phone: 443-945-4703
  • Fax:
Mailing address:
  • Phone: 484-442-0104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License NumberA01253
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: