MEDICARE: JACKSON RILEY HOLLAND MD

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	207Y00000X	Otolaryngology Physician	13619	WA

General Provider Information

NPI Number	:	1548356272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKSON RILEY HOLLAND MD

Provider Business Mailing Address
First Line	:	PO BOX 11009
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98508-1009
Country	:	US
Telephone Number	:	360-352-2037
Fax Number	:	360-352-0637

Provider Business Practice Location Address
First Line	:	1800 COOKS HILL RD
Second Line	:
City	:	CENTRALIA
State	:	WA
Zip	:	98531-9072
Country	:	US
Telephone Number	:	360-736-0168
Fax Number	:	360-330-8784

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

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	07/08/2007

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