Healthcare Provider Details

I. General information

NPI: 1194414805
Provider Name (Legal Business Name): HOLON HEALTH GREAT LAKES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11551 NUCKOLS RD STE R
GLEN ALLEN VA
23059-5565
US

IV. Provider business mailing address

3540 PUMP RD # 1188
RICHMOND VA
23233-1115
US

V. Phone/Fax

Practice location:
  • Phone: 877-465-6650
  • Fax: 804-294-2775
Mailing address:
  • Phone: 877-754-4694
  • Fax: 804-294-2775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JASON HERZOG
Title or Position: CEO
Credential:
Phone: 877-754-4694