Provider Demographics
NPI:1508183526
Name:HOLLAND, JACKIE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:HOLLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 W OKMULGEE ST STE M
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-6700
Mailing Address - Country:US
Mailing Address - Phone:918-360-3859
Mailing Address - Fax:918-681-4990
Practice Address - Street 1:1601 W OKMULGEE ST STE M
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-6700
Practice Address - Country:US
Practice Address - Phone:918-360-3859
Practice Address - Fax:918-681-4990
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-29
Last Update Date:2021-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker