Basic Information
| Provider Information | |||||||||
| NPI: | 1366533085 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOLLEY | ||||||||
| FirstName: | JEFF | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 56 MOONRAKER RD | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218111607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106035543 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 830 CHESAPEAKE DR | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216139408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102286305 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TA1056 | MD | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.