Provider Demographics
NPI:1336148451
Name:HOLLADA, JACK DEE (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:DEE
Last Name:HOLLADA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E BEARDSTOWN ST
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:IL
Mailing Address - Zip Code:62691-1304
Mailing Address - Country:US
Mailing Address - Phone:217-452-7252
Mailing Address - Fax:
Practice Address - Street 1:200 E BEARDSTOWN ST
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:IL
Practice Address - Zip Code:62691-1304
Practice Address - Country:US
Practice Address - Phone:217-452-7252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-004567111N00000X
FLCH4004111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
688960Medicare ID - Type Unspecified
T37864Medicare UPIN