Provider Demographics
NPI:1790127967
Name:HOLMES, JACQUELINE PRISCILLIA
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:PRISCILLIA
Last Name:HOLMES
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 1:5834 ARUBA WAY
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BCH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-1708
Mailing Address - Country:US
Mailing Address - Phone:904-554-0628
Mailing Address - Fax:
Practice Address - Street 1:5834 ARUBA WAY
Practice Address - Street 2:
Practice Address - City:WEST PALM BCH
Practice Address - State:FL
Practice Address - Zip Code:33407-1708
Practice Address - Country:US
Practice Address - Phone:904-554-0628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL136394376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide