Provider Demographics
NPI:1356126023
Name:JOLLY, JOSHUA ERVIN SR
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:ERVIN
Last Name:JOLLY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:589 PRESTON TRAILS DR
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147-2106
Mailing Address - Country:US
Mailing Address - Phone:614-596-4830
Mailing Address - Fax:
Practice Address - Street 1:4200 REGENT ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-6229
Practice Address - Country:US
Practice Address - Phone:614-596-4830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTT855006207Q00000X
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty