Provider Demographics
NPI:1003583725
Name:HOLLOWAY, JASON (PSYD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:HOLLOWAY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:
Other - Last Name:HOLLOWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:80 5TH AVE RM 1406
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-8015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:80 5TH AVE RM 1406
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8015
Practice Address - Country:US
Practice Address - Phone:914-980-5688
Practice Address - Fax:833-767-2931
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024522103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty