Provider Demographics
NPI:1407907504
Name:JOLLEY, TIMOTHY B (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:B
Last Name:JOLLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10209 136TH ST E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-3076
Mailing Address - Country:US
Mailing Address - Phone:253-848-1535
Mailing Address - Fax:253-848-6537
Practice Address - Street 1:1322 3RD ST SE STE 240
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3771
Practice Address - Country:US
Practice Address - Phone:253-848-1572
Practice Address - Fax:253-841-3719
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00015352208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1001502Medicaid
A08735Medicare UPIN