Basic Information
| Provider Information | |||||||||
| NPI: | 1902285646 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLTZ | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | WENDY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26666 | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871256666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059236770 | ||||||||
| FaxNumber: | 5059235354 | ||||||||
| Practice Location | |||||||||
| Address1: | 54 ST. MICHAELS DR. STE 200 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053035000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2015 | ||||||||
| LastUpdateDate: | 06/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 10091 | NE | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | 1514 | NM | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 390200000X | NM | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 103TC0700X | PSY1514 | NM | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.