Provider Demographics
NPI:1376000232
Name:HOLLINGSEAD, JEREMY C (FNP)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:C
Last Name:HOLLINGSEAD
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1700
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0414
Mailing Address - Country:US
Mailing Address - Phone:541-229-7038
Mailing Address - Fax:541-464-4474
Practice Address - Street 1:3031 NE STEPHENS ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-6237
Practice Address - Country:US
Practice Address - Phone:541-229-7038
Practice Address - Fax:541-464-4474
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201901586NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR201901586NP-PPMedicaid