Provider Demographics
NPI:1639149594
Name:HOLDREN, JACOB KYLE (DC)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:KYLE
Last Name:HOLDREN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 284
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:CO
Mailing Address - Zip Code:81047-0284
Mailing Address - Country:US
Mailing Address - Phone:719-537-0200
Mailing Address - Fax:
Practice Address - Street 1:209 S. MAIN STREET
Practice Address - Street 2:
Practice Address - City:HOLLY
Practice Address - State:CO
Practice Address - Zip Code:81047
Practice Address - Country:US
Practice Address - Phone:719-537-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04871111N00000X
COCHR.0007359111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS660064Medicare UPIN
KS062063Medicare ID - Type Unspecified