Healthcare Provider Details

I. General information

NPI: 1801477377
Provider Name (Legal Business Name): JENELL L HOLSTEAD PH.D., NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2021
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 CIRCLE DR STE B
GREEN BAY WI
54304-5569
US

IV. Provider business mailing address

1615 HIDDEN FALLS CT
DE PERE WI
54115-3389
US

V. Phone/Fax

Practice location:
  • Phone: 920-544-2780
  • Fax:
Mailing address:
  • Phone: 920-544-2780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: