Provider Demographics
NPI:1710304662
Name:HOLTBY, JORDAN NICHOLE (MED, ATR, LPC)
Entity Type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:NICHOLE
Last Name:HOLTBY
Suffix:
Gender:F
Credentials:MED, ATR, LPC
Other - Prefix:MISS
Other - First Name:JORDAN
Other - Middle Name:NICHOLE
Other - Last Name:RUDELIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23415 ROSEDALE RD
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-2752
Mailing Address - Country:US
Mailing Address - Phone:870-688-6185
Mailing Address - Fax:
Practice Address - Street 1:23415 ROSEDALE RD
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-2752
Practice Address - Country:US
Practice Address - Phone:870-688-6185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2023-04-14
Deactivation Date:2019-04-08
Deactivation Code:
Reactivation Date:2019-04-24
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 221700000X
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator