Provider Demographics
NPI:1598032229
Name:HOLMES, KENNETH JASON
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JASON
Last Name:HOLMES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-6502
Mailing Address - Country:US
Mailing Address - Phone:619-239-4663
Mailing Address - Fax:
Practice Address - Street 1:734 10TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-6502
Practice Address - Country:US
Practice Address - Phone:619-239-4663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-23
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT36002167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician