Provider Demographics
NPI:1891231601
Name:JOLLEY, SUKWAN (RD)
Entity Type:Individual
Prefix:MS
First Name:SUKWAN
Middle Name:
Last Name:JOLLEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 COLONY LAKE LN
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:TX
Mailing Address - Zip Code:77539-6169
Mailing Address - Country:US
Mailing Address - Phone:832-657-6056
Mailing Address - Fax:
Practice Address - Street 1:1124 COLUMBIA ST STE 400
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2053
Practice Address - Country:US
Practice Address - Phone:206-215-2090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001900133V00000X
TXDT81209133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered