Provider Demographics
NPI:1720824600
Name:PRAY-HOLMES, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PRAY-HOLMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2047 WADSBURY LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-6493
Mailing Address - Country:US
Mailing Address - Phone:719-209-9642
Mailing Address - Fax:
Practice Address - Street 1:1137 SAM RITTENBERG BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-3360
Practice Address - Country:US
Practice Address - Phone:843-763-0233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28959363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care