Provider Demographics
NPI:1245228485
Name:JAQUISH, KIM (RNP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:JAQUISH
Suffix:
Gender:F
Credentials:RNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 402319
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2319
Mailing Address - Country:US
Mailing Address - Phone:479-709-7399
Mailing Address - Fax:479-709-7053
Practice Address - Street 1:1500 DODSON AVE
Practice Address - Street 2:STE 125
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-5182
Practice Address - Country:US
Practice Address - Phone:479-573-7960
Practice Address - Fax:479-573-7961
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP01373363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR155652741Medicaid
OK100013980AMedicaid
OK100013980AMedicaid
AR155652741Medicaid