Provider Demographics
NPI:1982051876
Name:JOLLEY, LOUIS
Entity Type:Individual
Prefix:MR
First Name:LOUIS
Middle Name:
Last Name:JOLLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16040 IMPERIAL EAGLE COURT
Mailing Address - Street 2:
Mailing Address - City:WODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191
Mailing Address - Country:US
Mailing Address - Phone:678-542-5003
Mailing Address - Fax:
Practice Address - Street 1:16040 IMPERIAL EAGLE CT
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-6559
Practice Address - Country:US
Practice Address - Phone:678-542-5003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD06287776172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver