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General NPI Number Information
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NPI Number | 1194414805
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Entity Type | Organization
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Legal Business Name | HOLON HEALTH GREAT LAKES PC
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Dates
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Enumeration Date | 05/08/2023
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Last Update Date | 09/19/2025
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Provider Practice Location Address
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Address Line | 12077 GAYTON RD
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City | RICHMOND
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State | VA
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Zip | 23238-3401
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Country | US
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Telephone | 877-465-6650
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Fax | 804-294-2775
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Provider Business Mailing Address
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Address Line | 3540 PUMP RD # 1188
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City | RICHMOND
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State | VA
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Zip | 23233-1115
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Country | US
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Telephone | 804-404-6270
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. JASON HERZOG
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Credential |
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Telephone | 804-955-5246
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 2083A0300X
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Taxonomy Name | Addiction Medicine (Preventive Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 2084P0802X
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Taxonomy Name | Addiction Psychiatry Physician
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License Number |
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License Number State |
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