Provider Demographics
NPI:1780985721
Name:GOLLA, JACK GARY (QBA)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:GARY
Last Name:GOLLA
Suffix:
Gender:M
Credentials:QBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 WASHOE DR
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89704-9528
Mailing Address - Country:US
Mailing Address - Phone:775-849-3165
Mailing Address - Fax:775-849-9425
Practice Address - Street 1:670 WASHOE DR
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89704-9528
Practice Address - Country:US
Practice Address - Phone:775-849-3165
Practice Address - Fax:775-849-9425
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVFF467210251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9005043219Medicaid