Healthcare Provider Details

I. General information

NPI: 1073275939
Provider Name (Legal Business Name): KEONA MARIE JOLLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6224 JANICE PL
DAYTON OH
45415-1842
US

IV. Provider business mailing address

6224 JANICE PL
DAYTON OH
45415-1842
US

V. Phone/Fax

Practice location:
  • Phone: 937-287-6272
  • Fax:
Mailing address:
  • Phone: 937-287-6272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: