Provider Demographics
NPI:1114589751
Name:JOLLEY, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:JOLLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:581 W 1600 N STE B
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-2571
Mailing Address - Country:US
Mailing Address - Phone:385-331-2065
Mailing Address - Fax:801-797-1220
Practice Address - Street 1:494 W 1400 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-7001
Practice Address - Country:US
Practice Address - Phone:385-331-2065
Practice Address - Fax:801-797-1220
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-03
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
UT1101175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker