Provider Demographics
NPI:1760537815
Name:JOLLY, JENORA H (MD)
Entity Type:Individual
Prefix:
First Name:JENORA
Middle Name:H
Last Name:JOLLY
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:5055 E BROADWAY BLVD
Mailing Address - Street 2:A-100
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3640
Mailing Address - Country:US
Mailing Address - Phone:520-327-0460
Mailing Address - Fax:520-795-0225
Practice Address - Street 1:3190 N SWAN RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1227
Practice Address - Country:US
Practice Address - Phone:520-547-9700
Practice Address - Fax:520-547-9717
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2012-02-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ44155207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ143258OtherMEDICARE PTAN
AZ587584OtherAHCCCS