Provider Demographics
NPI:1578764049
Name:JOLLEY FAMILY ASSISTED LIVING HOME II
Entity Type:Organization
Organization Name:JOLLEY FAMILY ASSISTED LIVING HOME II
Other - Org Name:SHARON DUNCAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:LENORE
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-872-0032
Mailing Address - Street 1:5042 N 86TH DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-3313
Mailing Address - Country:US
Mailing Address - Phone:623-872-0032
Mailing Address - Fax:623-872-0033
Practice Address - Street 1:5042 N 86TH DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85305-3313
Practice Address - Country:US
Practice Address - Phone:623-872-0032
Practice Address - Fax:623-872-0033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH-4290311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ788812Medicaid