Provider Demographics
NPI:1275966210
Name:HOLUM, JENNIFER ALICIA (PLPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ALICIA
Last Name:HOLUM
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 E EAGLES VIEW CIR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65809-8904
Mailing Address - Country:US
Mailing Address - Phone:417-425-9850
Mailing Address - Fax:
Practice Address - Street 1:4102 E EAGLES VIEW CIR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65809-8904
Practice Address - Country:US
Practice Address - Phone:417-425-9850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012037168101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional