Provider Demographics
NPI:1699882217
Name:HOLTZ, JAN L (PHD, LP)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:L
Last Name:HOLTZ
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 NORTHWAY DRIVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1218
Mailing Address - Country:US
Mailing Address - Phone:320-253-4321
Mailing Address - Fax:320-240-8525
Practice Address - Street 1:1500 NORTHWAY DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1218
Practice Address - Country:US
Practice Address - Phone:320-253-4321
Practice Address - Fax:320-240-8525
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1014236OtherPREFERRED ONE PROVIDER NU
MN28Q49CEOtherBCBS GROUP NUMBER
MN6130168OtherMEDICA PROVIDER NUMBER
MN115380OtherBHP PROVIDER NUMBER
MN28Q24HOOtherBCBS IND PROVIDER NUMBER
MN92189OtherPREFERRED ONE GROUP NUMBE