Provider Demographics
NPI:1033506977
Name:JOLLY, ANN (LPN)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:JOLLY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:882 OAKMAN BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-4019
Mailing Address - Country:US
Mailing Address - Phone:313-967-5950
Mailing Address - Fax:
Practice Address - Street 1:882 OAKMAN BLVD STE B
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-4019
Practice Address - Country:US
Practice Address - Phone:313-967-5950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703052691164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse