Provider Demographics
NPI:1083808422
Name:ABRAHAM, JOLLY (PA-C)
Entity Type:Individual
Prefix:
First Name:JOLLY
Middle Name:
Last Name:ABRAHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 N SANGAMON ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-5955
Mailing Address - Country:US
Mailing Address - Phone:312-985-7150
Mailing Address - Fax:312-780-1462
Practice Address - Street 1:731 N SANGAMON ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-5955
Practice Address - Country:US
Practice Address - Phone:312-985-7150
Practice Address - Fax:312-780-1462
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003011363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical