Provider Demographics
NPI:1346341658
Name:JOLLEY, TERESA BARR (PA-C)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:BARR
Last Name:JOLLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:M
Other - Last Name:BARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 802843
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-2843
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:108 S HICKORY ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-1407
Practice Address - Country:US
Practice Address - Phone:417-466-4110
Practice Address - Fax:417-466-4255
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006006813363AM0700X
KYTC156363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
207076OtherBLUE CROSS OF MO
MO146240012Medicare PIN
207076OtherBLUE CROSS OF MO