MEDICARE: JESSICA JOLLY NBC-HWC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171400000X	Health & Wellness Coach

General Provider Information

NPI Number	:	1003567116
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA JOLLY NBC-HWC

Provider Business Mailing Address
First Line	:	2306 EUGENE ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75215-4036
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2306 EUGENE ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75215-4036
Country	:	US
Telephone Number	:	313-729-8053
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2022
Last Update Date	:	01/11/2022

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