Provider Demographics
NPI:1790816056
Name:JOLLY, CAROLINE ANN (PT)
Entity Type:Individual
Prefix:MS
First Name:CAROLINE
Middle Name:ANN
Last Name:JOLLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:CAROLINE
Other - Middle Name:ANN
Other - Last Name:JOLLY-PELOQUIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 1014
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1014
Mailing Address - Country:US
Mailing Address - Phone:732-855-9751
Mailing Address - Fax:732-855-9755
Practice Address - Street 1:1180 RARITAN RD
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1311
Practice Address - Country:US
Practice Address - Phone:908-276-2626
Practice Address - Fax:908-276-8260
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA008017002251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ039729ULKMedicare ID - Type UnspecifiedMEDICARE IDENTIFICATION