Provider Demographics
NPI:1841925765
Name:PRIVETT, JOLIE M
Entity type:Individual
Prefix:
First Name:JOLIE
Middle Name:M
Last Name:PRIVETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1149 TWIN BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27295-6021
Mailing Address - Country:US
Mailing Address - Phone:336-341-9463
Mailing Address - Fax:
Practice Address - Street 1:1000 VERMILLION ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:WV
Practice Address - Zip Code:24712-9027
Practice Address - Country:US
Practice Address - Phone:800-344-6679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-24
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer