Provider Demographics
NPI:1114574191
Name:HOLMES, JENNIFER ASHLEY GOOCH (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ASHLEY GOOCH
Last Name:HOLMES
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2357 E STATE ROAD 48
Mailing Address - Street 2:
Mailing Address - City:SHELBURN
Mailing Address - State:IN
Mailing Address - Zip Code:47879-8084
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 CRAWFORD ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-4614
Practice Address - Country:US
Practice Address - Phone:812-220-4755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009260A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily