Provider Demographics
NPI:1710905716
Name:HOLLEVOET, JACQUALIN
Entity Type:Individual
Prefix:
First Name:JACQUALIN
Middle Name:
Last Name:HOLLEVOET
Suffix:
Gender:F
Credentials:
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 688
Mailing Address - Street 2:
Mailing Address - City:CANDO
Mailing Address - State:ND
Mailing Address - Zip Code:58324-0688
Mailing Address - Country:US
Mailing Address - Phone:701-968-2541
Mailing Address - Fax:701-968-2574
Practice Address - Street 1:HYW 281N
Practice Address - Street 2:
Practice Address - City:CANDO
Practice Address - State:ND
Practice Address - Zip Code:58324-0688
Practice Address - Country:US
Practice Address - Phone:701-968-2541
Practice Address - Fax:701-968-2574
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0040363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND24026OtherBCBS PROVIDER #
ND17553OtherBCBS PROVIDER #
ND24026OtherBCBS PROVIDER #
S72103Medicare UPIN
17553Medicare ID - Type UnspecifiedPROVIDER # PART B