Provider Demographics
NPI:1194210393
Name:HOLTON, JARED T (CRNA)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:T
Last Name:HOLTON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 CENTURY DR STE E
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3699
Mailing Address - Country:US
Mailing Address - Phone:618-971-7919
Mailing Address - Fax:
Practice Address - Street 1:6800 STATE ROUTE 162
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8500
Practice Address - Country:US
Practice Address - Phone:800-281-3903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-29
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.017838367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered