Provider Demographics
NPI:1639681778
Name:JAISON, JOLLY
Entity Type:Individual
Prefix:
First Name:JOLLY
Middle Name:
Last Name:JAISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 E SAVANNAH AVE STE 14
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78503-1728
Mailing Address - Country:US
Mailing Address - Phone:956-668-1200
Mailing Address - Fax:956-668-1212
Practice Address - Street 1:1200 E SAVANNAH AVE STE 14
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-1728
Practice Address - Country:US
Practice Address - Phone:956-668-1200
Practice Address - Fax:956-668-1212
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF05170791207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine