Basic Information
| Provider Information | |||||||||
| NPI: | 1003017260 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLT | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 JAMAR ST | ||||||||
| Address2: | APT 5 | ||||||||
| City: | MOBERLY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652701906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733568811 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1515 UNION AVE | ||||||||
| Address2: | |||||||||
| City: | MOBERLY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652709407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6602693189 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 01/17/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 2005002981 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.