Provider Demographics
NPI:1386695765
Name:JOLLY, ANITA GALE (MA LLPC NCC)
Entity type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:GALE
Last Name:JOLLY
Suffix:
Gender:F
Credentials:MA LLPC NCC
Other - Prefix:
Other - First Name:ANITA
Other - Middle Name:
Other - Last Name:SAMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2273 SCOTT ROAD
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48461
Mailing Address - Country:US
Mailing Address - Phone:810-664-6502
Mailing Address - Fax:
Practice Address - Street 1:441 CLAY STREET
Practice Address - Street 2:CHRISTIAN FAMILY SERVICES OF LAPEER COUNTY
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446
Practice Address - Country:US
Practice Address - Phone:810-664-4557
Practice Address - Fax:810-664-5181
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008841101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional