Provider Demographics
NPI:1790228203
Name:JOLLY, MARJORIE DIANE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARJORIE
Middle Name:DIANE
Last Name:JOLLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARJORIE
Other - Middle Name:DIANE
Other - Last Name:HAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1402 W 14 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLAWSON
Mailing Address - State:MI
Mailing Address - Zip Code:48017-1499
Mailing Address - Country:US
Mailing Address - Phone:248-435-7314
Mailing Address - Fax:
Practice Address - Street 1:1402 W 14 MILE RD
Practice Address - Street 2:
Practice Address - City:CLAWSON
Practice Address - State:MI
Practice Address - Zip Code:48017-1499
Practice Address - Country:US
Practice Address - Phone:248-435-7314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-01
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008024363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant