Provider Demographics
NPI:1699058065
Name:JOLLY, KIMBERLY A (COTA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:JOLLY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3515 N 93RD AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-4672
Mailing Address - Country:US
Mailing Address - Phone:402-890-7883
Mailing Address - Fax:402-932-1888
Practice Address - Street 1:3110 SCOTT CIR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68112-2604
Practice Address - Country:US
Practice Address - Phone:402-203-6112
Practice Address - Fax:402-932-1888
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE872224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant