Provider Demographics
NPI:1811166002
Name:JOLLY, TRACY JEAN (BS)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:JEAN
Last Name:JOLLY
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1357 W SHAW AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3602
Mailing Address - Country:US
Mailing Address - Phone:559-221-7390
Mailing Address - Fax:
Practice Address - Street 1:1357 W SHAW AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3602
Practice Address - Country:US
Practice Address - Phone:559-221-7390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 10671225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist