Provider Demographics
NPI:1376180497
Name:JACOBS, KIMBERLY HEWLETT
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:HEWLETT
Last Name:JACOBS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:HEWLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-3328
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:12222 MERIT DR STE 600
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-3294
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020852367500000X
IL041445163367500000X
TX1049116367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered