MEDICARE: JOLLY THOMAS ANP

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	363LA2200X	Adult Health Nurse Practitioner	593284	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8N9803	OTHER	TX	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811961519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOLLY THOMAS ANP

Provider Business Mailing Address
First Line	:	PO BOX 660599
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75266-0599
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1936 AMELIA CT
Second Line	:	GERIATRIC CENTER & SENIOR SERVICES
City	:	DALLAS
State	:	TX
Zip	:	75235-7706
Country	:	US
Telephone Number	:	214-590-8369
Fax Number	:	214-590-8780

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

Provider Enumeration Date	:	02/17/2006
Last Update Date	:	12/03/2012

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Directions to “ JOLLY THOMAS ANP” Practice Location

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