Provider Demographics
NPI:1609456433
Name:JEFFERSON-HOLLIS, GLADYS
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:
Last Name:JEFFERSON-HOLLIS
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 1:5600 S WILLOW DR STE 203
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77035-4700
Mailing Address - Country:US
Mailing Address - Phone:832-775-3493
Mailing Address - Fax:
Practice Address - Street 1:5600 S WILLOW DR STE 203
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77035-4700
Practice Address - Country:US
Practice Address - Phone:832-775-3493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX820748994Medicaid