MEDICARE: JACQUELINE HOLLOWAY MS, LAT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	096.016073	IL

General Provider Information

NPI Number	:	1558224311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE HOLLOWAY MS, LAT, ATC

Provider Business Mailing Address
First Line	:	5257 LINDEN RD APT 10205
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61109-5859
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5050 E STATE ST
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-2311
Country	:	US
Telephone Number	:	815-394-3736
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2025
Last Update Date	:	12/08/2025

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