Provider Demographics
NPI:1467826248
Name:JACKSON, HOLLY (PA-C)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:KOONCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:805 HILL BLVD UNIT 104
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-1482
Mailing Address - Country:US
Mailing Address - Phone:817-573-5760
Mailing Address - Fax:
Practice Address - Street 1:4421 HIGHWAY 6 S STE 100
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-6176
Practice Address - Country:US
Practice Address - Phone:979-731-5200
Practice Address - Fax:979-731-5210
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10119363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant