Provider Demographics
NPI:1972832558
Name:HOLJENCIN, JACQUELYN ROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:ROSE
Last Name:HOLJENCIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:ROSE
Other - Last Name:SORG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:520 EAST 70TH STREET
Mailing Address - Street 2:STARR PAVILION 341
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021
Mailing Address - Country:US
Mailing Address - Phone:646-962-2064
Mailing Address - Fax:646-962-1605
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013596363AM0700X
PAMA054062363AM0700X
NC0010-09638363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical