Provider Demographics
NPI:1821687179
Name:HOLLEY, JORDAN ALYSSA HORNI
Entity Type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:ALYSSA HORNI
Last Name:HOLLEY
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 1:11521 N RR 620 RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78726-1139
Mailing Address - Country:US
Mailing Address - Phone:512-249-0577
Mailing Address - Fax:
Practice Address - Street 1:11521 N RR 620 RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78726-1139
Practice Address - Country:US
Practice Address - Phone:512-249-0577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX259682183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician