Provider Demographics
NPI:1275019895
Name:LOLLIS, JACKIE (LVN)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:LOLLIS
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 BUSCHONG ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77039-1206
Mailing Address - Country:US
Mailing Address - Phone:713-569-6435
Mailing Address - Fax:
Practice Address - Street 1:1617 BUSCHONG RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77039
Practice Address - Country:US
Practice Address - Phone:713-569-6435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX165924164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse