Provider Demographics
NPI:1366533085
Name:JOLLEY, JEFF (OD)
Entity type:Individual
Prefix:DR
First Name:JEFF
Middle Name:
Last Name:JOLLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 MOONRAKER RD
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1607
Mailing Address - Country:US
Mailing Address - Phone:410-603-5543
Mailing Address - Fax:
Practice Address - Street 1:830 CHESAPEAKE DR
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-9408
Practice Address - Country:US
Practice Address - Phone:410-228-6305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1056152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU12512Medicare UPIN