Provider Demographics
NPI:1902492705
Name:HOLNESS-WILSON, JAN
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:HOLNESS-WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N HIGHWAY 27 UNIT C
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-2447
Mailing Address - Country:US
Mailing Address - Phone:954-336-3734
Mailing Address - Fax:
Practice Address - Street 1:301 N HIGHWAY 27 UNIT C
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2447
Practice Address - Country:US
Practice Address - Phone:954-336-3734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA42231225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist