Provider Demographics
NPI:1972280196
Name:DAVE, JOLLY
Entity Type:Individual
Prefix:
First Name:JOLLY
Middle Name:
Last Name:DAVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11600 AUDELIA RD APT 132
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-4744
Mailing Address - Country:US
Mailing Address - Phone:980-327-9096
Mailing Address - Fax:
Practice Address - Street 1:3365 REGENT BLVD STE 130
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-3127
Practice Address - Country:US
Practice Address - Phone:469-647-4833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13677512251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic