Provider Demographics
NPI:1932660354
Name:SOREMEKUN-JOLLY, BEATRICE
Entity type:Individual
Prefix:
First Name:BEATRICE
Middle Name:
Last Name:SOREMEKUN-JOLLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1354 RAVENWOOD CT
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:TX
Mailing Address - Zip Code:76036-3472
Mailing Address - Country:US
Mailing Address - Phone:682-553-3208
Mailing Address - Fax:
Practice Address - Street 1:1354 RAVENWOOD CT
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:TX
Practice Address - Zip Code:76036-3472
Practice Address - Country:US
Practice Address - Phone:682-553-3208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2024-11-01
Deactivation Date:2022-08-10
Deactivation Code:
Reactivation Date:2024-06-11
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management
No251K00000XAgenciesPublic Health or Welfare
No172V00000XOther Service ProvidersCommunity Health Worker
No253J00000XAgenciesFoster Care Agency
No253Z00000XAgenciesIn Home Supportive Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81-4865224Medicaid