Provider Demographics
NPI:1386475556
Name:JOLLY, WILLIAM CODY
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:CODY
Last Name:JOLLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7162
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-7162
Mailing Address - Country:US
Mailing Address - Phone:909-487-9811
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 7162
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-7162
Practice Address - Country:US
Practice Address - Phone:909-487-9811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA148150106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist