Provider Demographics
NPI:1639701253
Name:GARCIA, JOLYN
Entity Type:Individual
Prefix:
First Name:JOLYN
Middle Name:
Last Name:GARCIA
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 1:616 S 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4806
Mailing Address - Country:US
Mailing Address - Phone:775-375-8015
Mailing Address - Fax:
Practice Address - Street 1:616 S 10TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4806
Practice Address - Country:US
Practice Address - Phone:775-375-8015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer