Healthcare Provider Details

I. General information

NPI: 1003017260
Provider Name (Legal Business Name): JENNIFER LYNN HOLT ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 01/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 UNION AVE
MOBERLY MO
65270-9407
US

IV. Provider business mailing address

100 JAMAR ST APT 5
MOBERLY MO
65270-1906
US

V. Phone/Fax

Practice location:
  • Phone: 660-269-3189
  • Fax:
Mailing address:
  • Phone: 573-356-8811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2005002981
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: