Provider Demographics
NPI:1154560233
Name:JOLLEY, REGINA L (RC)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:L
Last Name:JOLLEY
Suffix:
Gender:F
Credentials:RC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:WA
Mailing Address - Zip Code:99166-8804
Mailing Address - Country:US
Mailing Address - Phone:509-775-2504
Mailing Address - Fax:
Practice Address - Street 1:165 E HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-2629
Practice Address - Country:US
Practice Address - Phone:509-684-4597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00055894101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)