Provider Demographics
NPI:1396173175
Name:JANSEN, HOLLY (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:JANSEN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 GOLDEN ELM DR
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-4771
Mailing Address - Country:US
Mailing Address - Phone:785-577-1685
Mailing Address - Fax:
Practice Address - Street 1:305 GOLDEN ELM DR
Practice Address - Street 2:
Practice Address - City:SEFFNER
Practice Address - State:FL
Practice Address - Zip Code:33584-4771
Practice Address - Country:US
Practice Address - Phone:785-577-1685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-14
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13709235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14079079OtherASHA CERTIFICATE OF CLINICAL COMPETENCE
KS3574OtherSTATE OF KANSAS
FL13709OtherSTATE OF FLORIDA - DEPARTMENT OF HEALTH
CO0001400OtherCOLORADO SLP LICENSE