Healthcare Provider Details

I. General information

NPI: 1952237349
Provider Name (Legal Business Name): JACKLYN ANN HOLLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANCELA MYERS

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 KENNELFORD CIR
SACRAMENTO CA
95823-5319
US

IV. Provider business mailing address

101 KENNELFORD CIR
SACRAMENTO CA
95823-5319
US

V. Phone/Fax

Practice location:
  • Phone: 279-275-9773
  • Fax:
Mailing address:
  • Phone: 279-275-9773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number608191735
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: