=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780714600
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLA M JOLLY L.C.S.W.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 09/19/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 E 84TH ST SUITE 2
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10028-0902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-633-7100
-----------------------------------------------------
Fax | 212-633-7100
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 W 11TH ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10011-8607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-627-8144
-----------------------------------------------------
Fax | 212-633-7100
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 072235
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------