1609847300 NPI number — MRS. JENNIFER MICHELLE HOLLIDAY OTR L

Table of content: MRS. JENNIFER MICHELLE HOLLIDAY OTR L (NPI 1609847300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609847300 NPI number — MRS. JENNIFER MICHELLE HOLLIDAY OTR L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLLIDAY
Provider First Name:
JENNIFER
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MILLER
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR L
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609847300
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3457
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAREFREE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85377-3457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-595-2184
Provider Business Mailing Address Fax Number:
480-595-0212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17220 N BOSWELL BLVD
Provider Second Line Business Practice Location Address:
SUITE L200
Provider Business Practice Location Address City Name:
SUN CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85373-2000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-977-4911
Provider Business Practice Location Address Fax Number:
623-977-4919
Provider Enumeration Date:
01/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  3071 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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