MEDICARE: JACOB CHARLES HOLIEN

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	104100000X	Social Worker	IC-2683	NV

General Provider Information

NPI Number	:	1871488361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB CHARLES HOLIEN

Provider Business Mailing Address
First Line	:	3917 WHITE CASTLE ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-7076
Country	:	US
Telephone Number	:	763-233-8135
Fax Number	:

Provider Business Practice Location Address
First Line	:	3917 WHITE CASTLE ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-7076
Country	:	US
Telephone Number	:	763-233-8135
Fax Number	:

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

Provider Enumeration Date	:	06/12/2025
Last Update Date	:	06/12/2025

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