Provider Demographics
NPI:1457124661
Name:HOLCOMBE, JACK TAYLOR
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:TAYLOR
Last Name:HOLCOMBE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25590 PROSPECT AVE APT 23A
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25590 PROSPECT AVE APT 23A
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3148
Practice Address - Country:US
Practice Address - Phone:615-512-9410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist