Healthcare Provider Details

I. General information

NPI: 1770378937
Provider Name (Legal Business Name): JERRICA HOLLY LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JERRICA HOLLY LICSW

II. Dates (important events)

Enumeration Date: 04/10/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8716 E MILL PLAIN BLVD
VANCOUVER WA
98664-2531
US

IV. Provider business mailing address

6715 NE 63RD ST STE 267
VANCOUVER WA
98661-1980
US

V. Phone/Fax

Practice location:
  • Phone: 360-696-5300
  • Fax: 360-729-3372
Mailing address:
  • Phone: 816-518-9490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW61086180
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: