Provider Demographics
NPI:1366975054
Name:HOLT, JACORY (RADT)
Entity type:Individual
Prefix:
First Name:JACORY
Middle Name:
Last Name:HOLT
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40700 CALIFORNIA OAKS RD
Mailing Address - Street 2:202
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5795
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40700 CALIFORNIA OAKS RD
Practice Address - Street 2:202
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5795
Practice Address - Country:US
Practice Address - Phone:951-894-5072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1578665790Medicaid