Provider Demographics
NPI:1184144305
Name:JOLLEY, JACLYN JOHNSON (PA)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:JOHNSON
Last Name:JOLLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:JOHNSON
Other - Last Name:JOLLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:775 POLE LINE RD W STE 312
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5823
Practice Address - Country:US
Practice Address - Phone:208-814-8500
Practice Address - Fax:208-814-8960
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1520363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant