MEDICARE: JENNA HOLTZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	4687	ND

General Provider Information

NPI Number	:	1215461942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA HOLTZ

Provider Business Mailing Address
First Line	:	211 S 4TH ST
Second Line	:
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-4737
Country	:	US
Telephone Number	:	701-746-0405
Fax Number	:

Provider Business Practice Location Address
First Line	:	211 S 4TH ST
Second Line	:
City	:	GRAND FORKS
State	:	ND
Zip	:	58201-4737
Country	:	US
Telephone Number	:	701-746-0405
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2017
Last Update Date	:	04/19/2017

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