Provider Demographics
NPI:1770081408
Name:HOLSEN, JESSICA LEE (MA, BCBA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEE
Last Name:HOLSEN
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LEE
Other - Last Name:METZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:535 BROOKWOOD POINT PL APT 934
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-6912
Mailing Address - Country:US
Mailing Address - Phone:574-903-0305
Mailing Address - Fax:
Practice Address - Street 1:535 BROOKWOOD POINT PL APT 934
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-6912
Practice Address - Country:US
Practice Address - Phone:574-903-0305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1-17-28165103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst