MEDICARE: WILLIAM CODY JOLLY

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	106H00000X	Marriage & Family Therapist	148150	CA

General Provider Information

NPI Number	:	1386475556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM CODY JOLLY

Provider Business Mailing Address
First Line	:	PO BOX 7162
Second Line	:
City	:	LA VERNE
State	:	CA
Zip	:	91750-7162
Country	:	US
Telephone Number	:	909-487-9811
Fax Number	:

Provider Business Practice Location Address
First Line	:	3400 CENTRAL AVE STE 215
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-2176
Country	:	US
Telephone Number	:	951-934-8944
Fax Number	:

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

Provider Enumeration Date	:	08/09/2024
Last Update Date	:	10/13/2025

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