Provider Demographics
NPI:1003409780
Name:JOLLY, TORI (PA)
Entity type:Individual
Prefix:
First Name:TORI
Middle Name:
Last Name:JOLLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2510
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-2510
Mailing Address - Country:US
Mailing Address - Phone:706-922-8251
Mailing Address - Fax:706-922-6695
Practice Address - Street 1:131 RINEHART WAY
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-1703
Practice Address - Country:US
Practice Address - Phone:803-335-2200
Practice Address - Fax:803-649-7966
Is Sole Proprietor?:No
Enumeration Date:2021-02-15
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-11042363A00000X
SC4472363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4472OtherLICENSE
SC4472OtherLICENSE