Provider Demographics
NPI:1114239779
Name:HOLSONBACK, JILLIAN KATE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:KATE
Last Name:HOLSONBACK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:KATE
Other - Last Name:SALAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:304 EMORY ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1808
Mailing Address - Country:US
Mailing Address - Phone:229-244-1667
Mailing Address - Fax:229-244-8253
Practice Address - Street 1:304 EMORY ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602
Practice Address - Country:US
Practice Address - Phone:229-244-1667
Practice Address - Fax:229-244-8253
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-11
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15271225100000X
GAPT013371225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty