Provider Demographics
NPI:1457390858
Name:HOLLEN, JAKE THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:THOMAS
Last Name:HOLLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4311 SUFFOLK ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-3936
Mailing Address - Country:US
Mailing Address - Phone:337-477-9383
Mailing Address - Fax:
Practice Address - Street 1:4311 SUFFOLK ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-3936
Practice Address - Country:US
Practice Address - Phone:337-477-9383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013982208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1373150Medicaid
C67572Medicare UPIN
LA1373150Medicaid