Provider Demographics
NPI:1821527201
Name:HOLTON, JACOB PETER (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:PETER
Last Name:HOLTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4364
Mailing Address - Country:US
Mailing Address - Phone:309-662-3311
Mailing Address - Fax:
Practice Address - Street 1:2200 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4364
Practice Address - Country:US
Practice Address - Phone:309-662-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125070487207P00000X
IL036.152725207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine