Provider Demographics
NPI:1336659515
Name:HOLMAN, JESSICA RENEE (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:RENEE
Last Name:HOLMAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:RENEE
Other - Last Name:BOOTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:1755 ROADRUNNER LN
Mailing Address - Street 2:
Mailing Address - City:CHINO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86323-7105
Mailing Address - Country:US
Mailing Address - Phone:928-848-7553
Mailing Address - Fax:
Practice Address - Street 1:1755 ROADRUNNER LN
Practice Address - Street 2:
Practice Address - City:CHINO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86323-7105
Practice Address - Country:US
Practice Address - Phone:928-848-7553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10658363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily