Provider Demographics
NPI:1427843069
Name:HOLT, JENNA MOISE
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:MOISE
Last Name:HOLT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1268 W CLARK RD APT B6
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-9082
Mailing Address - Country:US
Mailing Address - Phone:210-213-9848
Mailing Address - Fax:
Practice Address - Street 1:1161 E CLARK RD STE 360-A
Practice Address - Street 2:
Practice Address - City:DEWITT
Practice Address - State:MI
Practice Address - Zip Code:48820-7930
Practice Address - Country:US
Practice Address - Phone:517-507-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-26-414422106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician