Provider Demographics
NPI:1689275802
Name:JACKSON, HOLLY MARIE
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:MARIE
Other - Last Name:PARDOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:448 W COOPER ST
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:MO
Mailing Address - Zip Code:65081-8217
Mailing Address - Country:US
Mailing Address - Phone:573-353-1292
Mailing Address - Fax:
Practice Address - Street 1:448 W COOPER ST
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:MO
Practice Address - Zip Code:65081-8217
Practice Address - Country:US
Practice Address - Phone:573-353-1292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant