Basic Information
Provider Information | |||||||||
NPI: | 1447624374 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOLLEY | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: | STEVEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | HAD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1001 E. SUNSET ROAD | ||||||||
Address2: | UNIT 96595 | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891931246 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7027980113 | ||||||||
FaxNumber: | 8662915242 | ||||||||
Practice Location | |||||||||
Address1: | 627 CHEROKEE ST | ||||||||
Address2: | SUITE 9 | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 30060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7705908662 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2015 | ||||||||
LastUpdateDate: | 11/23/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | HADS000886 | GA | Y |   | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |   |
No ID Information.