Provider Demographics
NPI:1841588498
Name:JACKLE, HOLLY ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:ANN
Last Name:JACKLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 BRUMMEL LN
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38558-2630
Mailing Address - Country:US
Mailing Address - Phone:615-609-6361
Mailing Address - Fax:866-341-7509
Practice Address - Street 1:28 BRUMMEL LN
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38558-2630
Practice Address - Country:US
Practice Address - Phone:615-609-6361
Practice Address - Fax:866-341-7509
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-18
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000031841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ000600Medicaid