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General NPI Number Information
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NPI Number | 1376294488
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Entity Type | Individual
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Provider Name | JORDAN JEFFREY JOLLY LCPC
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Gender | Male
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Dates
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Enumeration Date | 01/11/2022
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Last Update Date | 01/11/2022
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Provider Practice Location Address
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Address Line | 634 EDDY AVE
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City | MISSOULA
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State | MT
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Zip | 59812-1802
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Country | US
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Telephone | 406-243-4712
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Fax |
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Provider Business Mailing Address
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Address Line | 270 BROKEN TOP LN APT 212
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City | MISSOULA
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State | MT
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Zip | 59802-3252
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Country | US
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Telephone | 815-419-7204
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 51413
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License Number State | MT
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