Provider Demographics
NPI:1326719964
Name:KIRK, JACQUELINE ELISE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ELISE
Last Name:KIRK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:E
Other - Last Name:DODD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10004 KENNERLY RD STE 362B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2178
Mailing Address - Country:US
Mailing Address - Phone:314-525-5050
Mailing Address - Fax:314-525-5072
Practice Address - Street 1:10004 KENNERLY RD STE 362B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2178
Practice Address - Country:US
Practice Address - Phone:314-525-5050
Practice Address - Fax:314-525-5072
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021099690363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health