Provider Demographics
NPI:1811335326
Name:JOLLY, DASHEAVIA (RN)
Entity type:Individual
Prefix:
First Name:DASHEAVIA
Middle Name:
Last Name:JOLLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12550 CRENSHAW BLVD APT 219
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-3869
Mailing Address - Country:US
Mailing Address - Phone:478-978-3347
Mailing Address - Fax:
Practice Address - Street 1:1440 N HARBOR BLVD STE 916
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-4127
Practice Address - Country:US
Practice Address - Phone:478-978-3347
Practice Address - Fax:424-349-0011
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2023-01-30
Deactivation Date:2021-11-03
Deactivation Code:
Reactivation Date:2022-01-26
Provider Licenses
StateLicense IDTaxonomies
CA848-098163WH0200X, 163WI0500X
CA848098163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy