Individual
JOLLY THOMAS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
ANP
Contact information
Practice address
1936 AMELIA CT, GERIATRIC CENTER & SENIOR SERVICES, DALLAS, TX 75235-7706
(214) 590-8369
(214) 590-8780
Mailing address
PO BOX 660599, DALLAS, TX 75266-0599
Taxonomy
Speciality
Code
Description
License number
State
363LA2200X
Adult Health Nurse Practitioner
Primary
593284
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
179001601
—
TX
01
—
8N9803
BLUE CROSS BLUE SHIELD
TX
Enumeration date
02/17/2006
Last updated
12/03/2012
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