Provider Demographics
NPI:1487366571
Name:HOLDEN, JACK THOMAS
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:THOMAS
Last Name:HOLDEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 W 5TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030-6510
Mailing Address - Country:US
Mailing Address - Phone:805-382-2020
Mailing Address - Fax:
Practice Address - Street 1:1545 W 5TH ST STE 100
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-6510
Practice Address - Country:US
Practice Address - Phone:805-382-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35372152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist