Provider Demographics
NPI:1609612464
Name:HOLMES, JACQUELINE ELAINE (LDO)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ELAINE
Last Name:HOLMES
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 WATSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-8041
Mailing Address - Country:US
Mailing Address - Phone:478-971-4949
Mailing Address - Fax:478-971-7080
Practice Address - Street 1:2720 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-8041
Practice Address - Country:US
Practice Address - Phone:478-971-4949
Practice Address - Fax:478-971-7080
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002113156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician