MEDICARE: JORDAN ELICE TOLLEY

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1689338501
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN ELICE TOLLEY

Provider Business Mailing Address
First Line	:	651 W WARREN AVE STE 100
Second Line	:
City	:	LONGWOOD
State	:	FL
Zip	:	32750-4036
Country	:	US
Telephone Number	:	321-999-6405
Fax Number	:

Provider Business Practice Location Address
First Line	:	651 W WARREN AVE STE 100
Second Line	:
City	:	LONGWOOD
State	:	FL
Zip	:	32750-4036
Country	:	US
Telephone Number	:	321-999-6405
Fax Number	:

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

Provider Enumeration Date	:	10/27/2021
Last Update Date	:	10/27/2021

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Directions to “ JORDAN ELICE TOLLEY ” Practice Location

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