Provider Demographics
NPI:1811961519
Name:THOMAS, JOLLY (ANP)
Entity type:Individual
Prefix:
First Name:JOLLY
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1936 AMELIA CT
Practice Address - Street 2:GERIATRIC CENTER & SENIOR SERVICES
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7706
Practice Address - Country:US
Practice Address - Phone:214-590-8369
Practice Address - Fax:214-590-8780
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX593284363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N9803OtherBLUE CROSS BLUE SHIELD
TX179001601Medicaid
TX8G3332Medicare PIN
TXQ62094Medicare UPIN