=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821450651
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE ANN JOLLY MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2016
-----------------------------------------------------
Last Update Date | 11/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6580 KENWOOD CROSSING RD
-----------------------------------------------------
City | CRESTWOOD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40014-7614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-243-3161
-----------------------------------------------------
Fax | 502-243-3164
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2700 STANLEY GAULT PKWY STE 129
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40223-5176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-253-4900
-----------------------------------------------------
Fax | 502-489-5751
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 52514
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------