Healthcare Provider Details

I. General information

NPI: 1114574191
Provider Name (Legal Business Name): JENNIFER ASHLEY GOOCH HOLMES FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2019
Last Update Date: 08/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CRAWFORD ST
TERRE HAUTE IN
47807-4614
US

IV. Provider business mailing address

2357 E STATE ROAD 48
SHELBURN IN
47879-8084
US

V. Phone/Fax

Practice location:
  • Phone: 812-220-4755
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71009260A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: