Provider Demographics
NPI:1396380945
Name:HOLLOWAY, JEROME TAIJAY
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:TAIJAY
Last Name:HOLLOWAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3496 CHAPALA DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-1704
Mailing Address - Country:US
Mailing Address - Phone:408-912-6446
Mailing Address - Fax:
Practice Address - Street 1:39210 STATE ST.
Practice Address - Street 2:SUITE 220 FREMONT, CA 94538
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538
Practice Address - Country:US
Practice Address - Phone:510-894-4135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46-1305562106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician