Provider Demographics
NPI:1801477377
Name:HOLSTEAD, JENELL L (PHD, NCSP)
Entity type:Individual
Prefix:DR
First Name:JENELL
Middle Name:L
Last Name:HOLSTEAD
Suffix:
Gender:F
Credentials:PHD, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 HIDDEN FALLS CT
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-3389
Mailing Address - Country:US
Mailing Address - Phone:920-544-2780
Mailing Address - Fax:
Practice Address - Street 1:1050 CIRCLE DR STE B
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5569
Practice Address - Country:US
Practice Address - Phone:920-544-2780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy