Provider Demographics
NPI:1376155754
Name:HOLLOWAY, JACQUELYN H (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:H
Last Name:HOLLOWAY
Suffix:
Gender:F
Credentials:REGISTERED NURSE
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 1744
Mailing Address - Street 2:
Mailing Address - City:BEDRORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022
Mailing Address - Country:US
Mailing Address - Phone:405-596-2830
Mailing Address - Fax:
Practice Address - Street 1:801 FOREST RIDGE DR STE 104
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-7240
Practice Address - Country:US
Practice Address - Phone:405-596-2830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX890576163W00000X, 163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, AdultGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty