Provider Demographics
NPI:1487176475
Name:JIMMERSON, HOLLY ANN (SLPA)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:ANN
Last Name:JIMMERSON
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17677 W LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-6081
Mailing Address - Country:US
Mailing Address - Phone:850-728-7036
Mailing Address - Fax:
Practice Address - Street 1:17677 W LINCOLN ST
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-6081
Practice Address - Country:US
Practice Address - Phone:850-728-7036
Practice Address - Fax:850-728-7036
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-11
Last Update Date:2017-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA10647235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist