Provider Demographics
NPI:1689949208
Name:JACKSON, HOLIDAY TEMPLE (DC)
Entity Type:Individual
Prefix:DR
First Name:HOLIDAY
Middle Name:TEMPLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 ANITA AVE
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-4904
Mailing Address - Country:US
Mailing Address - Phone:831-219-6909
Mailing Address - Fax:
Practice Address - Street 1:163 ANITA AVE
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-4904
Practice Address - Country:US
Practice Address - Phone:831-219-6909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19167111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor