Healthcare Provider Details

I. General information

NPI: 1154301463
Provider Name (Legal Business Name): ANDREA B JOLLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDREA B JOLLEY M.D.

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 HOSPITAL DR
WINDOM MN
56101-1287
US

IV. Provider business mailing address

1600 UTICA AVE S
ST LOUIS PARK MN
55416-1443
US

V. Phone/Fax

Practice location:
  • Phone: 877-949-5678
  • Fax:
Mailing address:
  • Phone: 612-412-7260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number44971
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number62084
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35C.001893
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number46464
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number46464
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: