Basic Information
| Provider Information | |||||||||
| NPI: | 1356402648 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOLLEY | ||||||||
| FirstName: | DONNA | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1707 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546014200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087850001 | ||||||||
| FaxNumber: | 6087850002 | ||||||||
| Practice Location | |||||||||
| Address1: | 1321 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | VIROQUA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546651156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6086377052 | ||||||||
| FaxNumber: | 6086378500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 09/12/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 3616-123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 39082186305 | 01 | WI | UNITY HEALTH INSURANCE | OTHER | 39693200 | 05 | WI | MEDICAID | HP66985 | 01 | MN | HEALTHPARTNERS | OTHER | 13G85JO | 01 | MN | BCBS-MN | OTHER |