Healthcare Provider Details

I. General information

NPI: 1750594768
Provider Name (Legal Business Name): JAN LEE HOLTBERG WHCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 S. WEST STREET
ARLINGTON TX
76010
US

IV. Provider business mailing address

6055 NORWAY RD
DALLAS TX
75230-4056
US

V. Phone/Fax

Practice location:
  • Phone: 817-272-2771
  • Fax: 817-272-3829
Mailing address:
  • Phone: 214-265-7087
  • Fax: 817-272-3829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number602940
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: