Provider Demographics
NPI:1619962982
Name:JOLLY, CHRISTINE M (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:M
Last Name:JOLLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8600 75TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-8200
Mailing Address - Country:US
Mailing Address - Phone:262-652-9430
Mailing Address - Fax:262-652-9433
Practice Address - Street 1:8600 75TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-8200
Practice Address - Country:US
Practice Address - Phone:262-652-9430
Practice Address - Fax:262-652-9433
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI41723208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32526900Medicaid
WI32526900Medicaid