Provider Demographics
NPI:1326792268
Name:HOLTHAUS, JERRICA
Entity Type:Individual
Prefix:
First Name:JERRICA
Middle Name:
Last Name:HOLTHAUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 LOY RD
Mailing Address - Street 2:
Mailing Address - City:FORT LORAMIE
Mailing Address - State:OH
Mailing Address - Zip Code:45845-9713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11230 STATE ROUTE 364
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-9534
Practice Address - Country:US
Practice Address - Phone:419-394-6757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist