Provider Demographics
NPI:1821339847
Name:JOLLY, GREGORY WILLIAM (LMT)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:WILLIAM
Last Name:JOLLY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5653 N STANTON DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-4357
Mailing Address - Country:US
Mailing Address - Phone:414-238-3229
Mailing Address - Fax:
Practice Address - Street 1:8320 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-3367
Practice Address - Country:US
Practice Address - Phone:414-302-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-15
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI821-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist