Provider Demographics
NPI:1790362804
Name:HOLSTON, JAMILA (DO)
Entity Type:Individual
Prefix:DR
First Name:JAMILA
Middle Name:
Last Name:HOLSTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6518 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-3624
Mailing Address - Country:US
Mailing Address - Phone:856-842-8414
Mailing Address - Fax:
Practice Address - Street 1:6518 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-3624
Practice Address - Country:US
Practice Address - Phone:856-842-8414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2023-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS022713208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program