Provider Demographics
NPI:1194053058
Name:JOLLY, HEATHER (MA, NCSP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:JOLLY
Suffix:
Gender:F
Credentials:MA, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15867 N 74TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-1812
Mailing Address - Country:US
Mailing Address - Phone:623-910-1133
Mailing Address - Fax:
Practice Address - Street 1:3401 N 67TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-4517
Practice Address - Country:US
Practice Address - Phone:623-691-4085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool