Provider Demographics
NPI:1285391433
Name:JOLLY, AMY EVANS (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:EVANS
Last Name:JOLLY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MICHELLE
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:PO BOX 998
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:TX
Mailing Address - Zip Code:75563-0998
Mailing Address - Country:US
Mailing Address - Phone:903-399-1316
Mailing Address - Fax:
Practice Address - Street 1:612 S GROVE ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-5219
Practice Address - Country:US
Practice Address - Phone:903-399-1316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100860235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist