Provider Demographics
NPI:1134421183
Name:HOLLEY, JADE LYNN (PAC)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:LYNN
Last Name:HOLLEY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MOOSIC
Mailing Address - State:PA
Mailing Address - Zip Code:18507-1001
Mailing Address - Country:US
Mailing Address - Phone:570-471-3569
Mailing Address - Fax:
Practice Address - Street 1:532 MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:MOOSIC
Practice Address - State:PA
Practice Address - Zip Code:18507-1001
Practice Address - Country:US
Practice Address - Phone:570-471-3569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-24
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054639363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103213688-0001Medicaid
PA410559J67Medicare PIN