Provider Demographics
NPI:1144338781
Name:HOLDER, JACQUELINE (DO)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:HOLDER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4214
Mailing Address - Country:US
Mailing Address - Phone:812-242-3105
Mailing Address - Fax:812-242-3133
Practice Address - Street 1:221 S 6TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-4214
Practice Address - Country:US
Practice Address - Phone:812-242-3105
Practice Address - Fax:812-242-3133
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002477A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000224510OtherANTHEM
IN200373360Medicaid
000000224510OtherANTHEM
IN265130AAAMedicare PIN
P05701Medicare UPIN
IN200373360Medicaid