Healthcare Provider Details

I. General information

NPI: 1235120601
Provider Name (Legal Business Name): JON R JOLLES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 MILL ST BUILDING E - 17
HANOVER MA
02339-1641
US

IV. Provider business mailing address

PO BOX 68
S WEYMOUTH MA
02190-0001
US

V. Phone/Fax

Practice location:
  • Phone: 781-826-2131
  • Fax: 781-826-4513
Mailing address:
  • Phone: 781-803-2786
  • Fax: 781-812-1631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number45558
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: