Provider Demographics
NPI:1699852897
Name:JOLLY, JENNIFER (CTRS)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:JOLLY
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:NASSIMOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CTRS
Mailing Address - Street 1:606 E CYPRESS AVE
Mailing Address - Street 2:APT. C
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91501-1877
Mailing Address - Country:US
Mailing Address - Phone:818-972-2983
Mailing Address - Fax:
Practice Address - Street 1:1224 VINE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-1612
Practice Address - Country:US
Practice Address - Phone:323-769-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46425225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist