Provider Demographics
NPI:1952385148
Name:HOLDEMAN, JASON TODD (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:TODD
Last Name:HOLDEMAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MISTY HILL LN
Mailing Address - Street 2:
Mailing Address - City:HAINESVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-1078
Mailing Address - Country:US
Mailing Address - Phone:630-621-0368
Mailing Address - Fax:
Practice Address - Street 1:3420 ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088-3161
Practice Address - Country:US
Practice Address - Phone:847-688-6755
Practice Address - Fax:847-688-7411
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041693A103T00000X
IL071-006876103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist