=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235120601
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JON R JOLLES MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2005
-----------------------------------------------------
Last Update Date | 10/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 51 MILL ST BUILDING E - 17
-----------------------------------------------------
City | HANOVER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02339-1641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-826-2131
-----------------------------------------------------
Fax | 781-826-4513
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 68
-----------------------------------------------------
City | S WEYMOUTH
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02190-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-803-2786
-----------------------------------------------------
Fax | 781-812-1631
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 45558
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------