Healthcare Provider Details

I. General information

NPI: 1851483242
Provider Name (Legal Business Name): JACOB P HOLKUP DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S CENTRAL AVE
BEACH ND
58621-4001
US

IV. Provider business mailing address

PO BOX 908
BEACH ND
58621-0908
US

V. Phone/Fax

Practice location:
  • Phone: 701-872-7520
  • Fax: 701-872-7521
Mailing address:
  • Phone: 701-872-7520
  • Fax: 701-872-7521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number729
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301009112
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4356
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: