Healthcare Provider Details

I. General information

NPI: 1316693211
Provider Name (Legal Business Name): MARY JUANITA JOLLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S 4TH ST
LOUISVILLE KY
40203-3205
US

IV. Provider business mailing address

2515 MONTGOMERY ST
LOUISVILLE KY
40212-1019
US

V. Phone/Fax

Practice location:
  • Phone: 502-585-9911
  • Fax:
Mailing address:
  • Phone: 502-296-5272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: