Healthcare Provider Details

I. General information

NPI: 1366339004
Provider Name (Legal Business Name): MARY KATHARINE JOLLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 ANDERSON FERRY RD APT 42
CINCINNATI OH
45238-5913
US

IV. Provider business mailing address

171 ANDERSON FERRY RD APT 42
CINCINNATI OH
45238-5913
US

V. Phone/Fax

Practice location:
  • Phone: 512-808-6270
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: