Healthcare Provider Details

I. General information

NPI: 1558224311
Provider Name (Legal Business Name): JACQUELINE HOLLOWAY MS, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 E STATE ST
ROCKFORD IL
61108-2311
US

IV. Provider business mailing address

5257 LINDEN RD APT 10205
ROCKFORD IL
61109-5859
US

V. Phone/Fax

Practice location:
  • Phone: 815-394-3736
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.016073
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: