Provider Demographics
NPI:1497480784
Name:HOLTON, JESSIE HAROLD EDWARD (EDD)
Entity Type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:HAROLD EDWARD
Last Name:HOLTON
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 E FORK RD
Mailing Address - Street 2:
Mailing Address - City:BIG TIMBER
Mailing Address - State:MT
Mailing Address - Zip Code:59011-7805
Mailing Address - Country:US
Mailing Address - Phone:321-289-0068
Mailing Address - Fax:
Practice Address - Street 1:2216 BOOT HILL CT STE 3
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-7215
Practice Address - Country:US
Practice Address - Phone:406-600-5007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-ACLC-LIC-56946101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)