Provider Demographics
NPI:1225072341
Name:HOLLAND, JEANNETTE LORRAINE (OD)
Entity type:Individual
Prefix:DR
First Name:JEANNETTE
Middle Name:LORRAINE
Last Name:HOLLAND
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JEANNETTE
Other - Middle Name:LORRAINE
Other - Last Name:BAZE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1106 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:KS
Mailing Address - Zip Code:66066-4203
Mailing Address - Country:US
Mailing Address - Phone:785-863-2000
Mailing Address - Fax:785-863-3333
Practice Address - Street 1:1106 WALNUT ST
Practice Address - Street 2:
Practice Address - City:OSKALOOSA
Practice Address - State:KS
Practice Address - Zip Code:66066-4203
Practice Address - Country:US
Practice Address - Phone:785-863-2000
Practice Address - Fax:785-863-3333
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1446-3152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
410039156OtherRAILROAD MEDICARE
KS1225072341Medicaid
KS1252970001Medicare NSC
KSU58013Medicare UPIN