Provider Demographics
NPI:1922108703
Name:JOLLY, LINDA S (WSC)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:S
Last Name:JOLLY
Suffix:
Gender:F
Credentials:WSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 NW 172ND CT
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34972-8480
Mailing Address - Country:US
Mailing Address - Phone:863-467-0014
Mailing Address - Fax:772-468-9360
Practice Address - Street 1:800 VIRGINIA AVE STE 59 F
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-5892
Practice Address - Country:US
Practice Address - Phone:772-468-9333
Practice Address - Fax:772-468-9360
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL68994868Medicaid