Provider Demographics
NPI:1588675631
Name:HOLDREN, JEAN A (DO PC)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:A
Last Name:HOLDREN
Suffix:
Gender:F
Credentials:DO PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16687 ST CLAIR AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920
Mailing Address - Country:US
Mailing Address - Phone:330-386-5004
Mailing Address - Fax:330-386-6355
Practice Address - Street 1:16687 ST CLAIR AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920
Practice Address - Country:US
Practice Address - Phone:330-386-5004
Practice Address - Fax:330-386-6355
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006738207R00000X
PA0S009111L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F77504Medicare UPIN