Basic Information
| Provider Information | |||||||||
| NPI: | 1619962982 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOLLY | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8600 75TH ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531428200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626529430 | ||||||||
| FaxNumber: | 2626529433 | ||||||||
| Practice Location | |||||||||
| Address1: | 8600 75TH ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531428200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626529430 | ||||||||
| FaxNumber: | 2626529433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 04/08/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 41723 | WI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 32526900 | 05 | WI | MEDICAID |