Provider Demographics
NPI:1689980401
Name:JOLLY, REBECCA BRYANT
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:BRYANT
Last Name:JOLLY
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 1:155 GROGANS LNDG
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30350-3131
Mailing Address - Country:US
Mailing Address - Phone:770-393-8366
Mailing Address - Fax:
Practice Address - Street 1:4545 E SHEA BLVD
Practice Address - Street 2:STE. 175
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3074
Practice Address - Country:US
Practice Address - Phone:602-464-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA147381363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily