Provider Demographics
NPI:1629849427
Name:HOLIDAY, JONATHAN DWAYNE (LADACLL)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:DWAYNE
Last Name:HOLIDAY
Suffix:
Gender:M
Credentials:LADACLL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4330 FREEMARK DR
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-8417
Mailing Address - Country:US
Mailing Address - Phone:615-604-6988
Mailing Address - Fax:
Practice Address - Street 1:4330 FREEMARK DR
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-8417
Practice Address - Country:US
Practice Address - Phone:615-604-6988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDC0000001255101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)