Healthcare Provider Details

I. General information

NPI: 1548356272
Provider Name (Legal Business Name): JACKSON RILEY HOLLAND MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 COOKS HILL RD
CENTRALIA WA
98531-9072
US

IV. Provider business mailing address

PO BOX 11009
OLYMPIA WA
98508-1009
US

V. Phone/Fax

Practice location:
  • Phone: 360-736-0168
  • Fax: 360-330-8784
Mailing address:
  • Phone: 360-352-2037
  • Fax: 360-352-0637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number13619
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: