Healthcare Provider Details

I. General information

NPI: 1750141735
Provider Name (Legal Business Name): JESSE JOLLY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 E 19TH ST STE 703
TULSA OK
74104-5418
US

IV. Provider business mailing address

29514 E 79TH ST S
BROKEN ARROW OK
74014-5057
US

V. Phone/Fax

Practice location:
  • Phone: 918-382-3178
  • Fax:
Mailing address:
  • Phone: 817-247-3859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number9125
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: