Provider Demographics
NPI:1083176283
Name:JOLLY, MARY CLAIRE (FITTER/DISPENSER)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:CLAIRE
Last Name:JOLLY
Suffix:
Gender:F
Credentials:FITTER/DISPENSER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 BAGANIE LN
Mailing Address - Street 2:
Mailing Address - City:BULLARD
Mailing Address - State:TX
Mailing Address - Zip Code:75757-3010
Mailing Address - Country:US
Mailing Address - Phone:903-330-6798
Mailing Address - Fax:
Practice Address - Street 1:4746 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1308
Practice Address - Country:US
Practice Address - Phone:903-561-8774
Practice Address - Fax:903-561-8787
Is Sole Proprietor?:No
Enumeration Date:2019-04-05
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80480237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist