Provider Demographics
NPI:1265837827
Name:KEROUAC, JACULIN (AGACNP)
Entity Type:Individual
Prefix:
First Name:JACULIN
Middle Name:
Last Name:KEROUAC
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 N SCOTTSDALE RD STE 320
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-5650
Mailing Address - Country:US
Mailing Address - Phone:480-882-5740
Mailing Address - Fax:
Practice Address - Street 1:3501 N SCOTTSDALE RD STE 320
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-5650
Practice Address - Country:US
Practice Address - Phone:480-882-5740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-24
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7409363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care