Provider Demographics
NPI:1942697495
Name:HOLLIS, JASON BOYD (DO)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:BOYD
Last Name:HOLLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 OLD GROVELAND RD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:GA
Mailing Address - Zip Code:31321-3177
Mailing Address - Country:US
Mailing Address - Phone:276-591-8383
Mailing Address - Fax:
Practice Address - Street 1:1140 BRAMPTON AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0847
Practice Address - Country:US
Practice Address - Phone:912-871-2273
Practice Address - Fax:912-871-2274
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-17756207Q00000X
GA80316207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110902000Medicaid