Provider Demographics
NPI:1225847759
Name:JOLLEY, MASHONDA MICHELLE
Entity type:Individual
Prefix:
First Name:MASHONDA
Middle Name:MICHELLE
Last Name:JOLLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 KENTSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-2316
Mailing Address - Country:US
Mailing Address - Phone:912-223-8723
Mailing Address - Fax:
Practice Address - Street 1:105 KENTSHIRE AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-2316
Practice Address - Country:US
Practice Address - Phone:912-223-8723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician