Provider Demographics
NPI:1548227879
Name:JOLLEY, JILL M (PAC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:M
Last Name:JOLLEY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:M
Other - Last Name:WIECH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1900 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-3332
Mailing Address - Country:US
Mailing Address - Phone:716-712-0670
Mailing Address - Fax:716-716-0674
Practice Address - Street 1:1900 RIDGE RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-3332
Practice Address - Country:US
Practice Address - Phone:716-712-0670
Practice Address - Fax:716-712-0674
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052482363A00000X
NY010802363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ69544Medicare UPIN
PA101041LPBMedicare PIN