Provider Demographics
NPI:1417069782
Name:HOLMAN, JENNIFER RACHELLE (RD/LD-CDE)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RACHELLE
Last Name:HOLMAN
Suffix:
Gender:F
Credentials:RD/LD-CDE
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RACHELLE
Other - Last Name:BAILEY-HOLMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:408 S CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-6602
Mailing Address - Country:US
Mailing Address - Phone:918-774-5074
Mailing Address - Fax:
Practice Address - Street 1:408 S CHERRY ST
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-6602
Practice Address - Country:US
Practice Address - Phone:918-774-5074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLD1057133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200057610AMedicaid
OK200057610BOtherOHCA DDSD WAIVER
OK8E279BOtherPART B
OK200057610BOtherOHCA DDSD WAIVER