Provider Demographics
NPI:1720854615
Name:JOLLY, TIAMOYA
Entity type:Individual
Prefix:
First Name:TIAMOYA
Middle Name:
Last Name:JOLLY
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 1:19 S WEYANT AVE APT C
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1679
Mailing Address - Country:US
Mailing Address - Phone:614-254-2440
Mailing Address - Fax:614-953-2802
Practice Address - Street 1:513 E RICH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5376
Practice Address - Country:US
Practice Address - Phone:614-674-6084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-30
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHAPS.005635175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care Coordinator