Provider Demographics
NPI:1366006256
Name:JOLLEY, MATTHEW C (LMT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:C
Last Name:JOLLEY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S ELM ST APT 5
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-2630
Mailing Address - Country:US
Mailing Address - Phone:970-639-2629
Mailing Address - Fax:
Practice Address - Street 1:514 28 1/4 RD UNIT 1
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-4961
Practice Address - Country:US
Practice Address - Phone:970-242-8162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-25
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0018908225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0018908OtherCOLORADO DIVISION OF REGULATORY AGENCIES