Healthcare Provider Details

I. General information

NPI: 1457021180
Provider Name (Legal Business Name): JYLLIAN HOLMES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2021
Last Update Date: 09/14/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 SOUTHPARK BLVD STE 100
ST AUGUSTINE FL
32086-4209
US

IV. Provider business mailing address

9645 BAYMEADOWS RD APT 909
JACKSONVILLE FL
32256-7823
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-1478
  • Fax:
Mailing address:
  • Phone: 315-272-8068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: