Basic Information
| Provider Information | |||||||||
| NPI: | 1619929437 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLTHAUS | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 632778 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452632778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138917574 | ||||||||
| FaxNumber: | 5137931032 | ||||||||
| Practice Location | |||||||||
| Address1: | 4015 EXECUTIVE PARK DR | ||||||||
| Address2: | STE 406 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452414017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135696747 | ||||||||
| FaxNumber: | 5135696988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 11/30/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | NP-06838 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 2592494 | 05 | OH | MEDICAID | P00287513 | 01 | OH | RAILROAD MEDICARE | OTHER |