Provider Demographics
NPI:1174662928
Name:HOLLAND, JEROME (GSW)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:
Last Name:HOLLAND
Suffix:
Gender:M
Credentials:GSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1723 N TALLOWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-6409
Mailing Address - Country:US
Mailing Address - Phone:504-638-1086
Mailing Address - Fax:
Practice Address - Street 1:4105 KIRKMAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-4603
Practice Address - Country:US
Practice Address - Phone:337-475-8022
Practice Address - Fax:337-475-8054
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA67561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical