Provider Demographics
NPI:1356895007
Name:JOLLY, MARVA LYNN (MNT)
Entity type:Individual
Prefix:
First Name:MARVA
Middle Name:LYNN
Last Name:JOLLY
Suffix:
Gender:F
Credentials:MNT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4596 S JASON ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80110-5606
Mailing Address - Country:US
Mailing Address - Phone:303-478-8047
Mailing Address - Fax:
Practice Address - Street 1:4596 S JASON ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80110-5606
Practice Address - Country:US
Practice Address - Phone:303-478-8047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO06092016133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist