Provider Demographics
NPI:1275009581
Name:JOLLY, JUDITH A (RN)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:JOLLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N6421 RAVEN RD
Mailing Address - Street 2:
Mailing Address - City:PARDEEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53954-8917
Mailing Address - Country:US
Mailing Address - Phone:214-417-2089
Mailing Address - Fax:
Practice Address - Street 1:N6421 RAVEN RD
Practice Address - Street 2:
Practice Address - City:PARDEEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53954-8917
Practice Address - Country:US
Practice Address - Phone:214-417-2089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI242442-30163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health