Provider Demographics
NPI:1750141735
Name:JOLLY, JESSE (DO)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:JOLLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 E GALLUP HILL RD
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-8864
Mailing Address - Country:US
Mailing Address - Phone:817-247-3859
Mailing Address - Fax:
Practice Address - Street 1:1705 E 19TH ST STE 703
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5418
Practice Address - Country:US
Practice Address - Phone:918-382-3178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0763R390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program