Provider Demographics
NPI:1225708514
Name:JOLLY, SARAH (PA-C)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:JOLLY
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 1:2800 E BROAD ST STE 514
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-6417
Mailing Address - Country:US
Mailing Address - Phone:817-465-5311
Mailing Address - Fax:817-465-8569
Practice Address - Street 1:2800 E BROAD ST STE 514
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-6417
Practice Address - Country:US
Practice Address - Phone:817-465-5311
Practice Address - Fax:817-465-8569
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA14992363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TEMPORARYOtherTMB LICENSE