Healthcare Provider Details

I. General information

NPI: 1467124628
Provider Name (Legal Business Name): JENNIFER ELIZABETH HOLLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 MAIN ST
NEW LONDON NH
03257-7835
US

IV. Provider business mailing address

751 OLD BASS RIVER RD
DENNIS MA
02638-2503
US

V. Phone/Fax

Practice location:
  • Phone: 508-360-9157
  • Fax:
Mailing address:
  • Phone: 508-360-9157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: