Provider Demographics
NPI:1649349259
Name:HOLLEY, JEAN L (MD)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:L
Last Name:HOLLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:611 W. PARK ST.
Practice Address - Street 2:NEPHROLOGY
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2500
Practice Address - Country:US
Practice Address - Phone:217-383-3605
Practice Address - Fax:217-383-2704
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231892207RN0300X
IL03606251207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005865051Medicaid
IL6447860011Medicare NSC
ILIL3270023Medicare PIN
A72487Medicare UPIN
VA005865051Medicaid
IL6447860011Medicare NSC