Provider Demographics
NPI:1437450616
Name:HOLT, JERRY LEE (LPC, LPCC LADC)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LEE
Last Name:HOLT
Suffix:
Gender:M
Credentials:LPC, LPCC LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13895 INDUSTRIAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-3700
Mailing Address - Country:US
Mailing Address - Phone:763-300-6707
Mailing Address - Fax:763-559-2116
Practice Address - Street 1:13895 INDUSTRIAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-3700
Practice Address - Country:US
Practice Address - Phone:763-300-6707
Practice Address - Fax:763-559-2116
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302560101YA0400X
MNLPC00797101YM0800X
MN00416101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)