Provider Demographics
NPI:1750586053
Name:HOLT, MARY JEANNE (DC)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:JEANNE
Last Name:HOLT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 TROY CIR
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-3246
Mailing Address - Country:US
Mailing Address - Phone:731-285-5341
Mailing Address - Fax:731-285-5341
Practice Address - Street 1:118 TROY CIR
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-3246
Practice Address - Country:US
Practice Address - Phone:731-285-5341
Practice Address - Fax:731-285-5341
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN437111N00000X
WA2052111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T02002Medicare UPIN
WAAB34045Medicare ID - Type UnspecifiedPROVIDER NUMBER