Provider Demographics
NPI:1104962919
Name:JOLLEY, CRISTINA (LPCC)
Entity type:Individual
Prefix:
First Name:CRISTINA
Middle Name:
Last Name:JOLLEY
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14161 W RIVER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA STATION
Mailing Address - State:OH
Mailing Address - Zip Code:44028-8953
Mailing Address - Country:US
Mailing Address - Phone:440-879-8090
Mailing Address - Fax:
Practice Address - Street 1:14161 W RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA STATION
Practice Address - State:OH
Practice Address - Zip Code:44028-8953
Practice Address - Country:US
Practice Address - Phone:440-879-8090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0501023101YP2500X
OH090302101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341690006OtherTAX IDENTIFICATION NUMBER