Provider Demographics
NPI:1548735384
Name:GRIMES, JACQUELINE LEIGHT REICHERT
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LEIGHT REICHERT
Last Name:GRIMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 FARMINGTON DR
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE PARK
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3195
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:334 FARMINGTON DR
Practice Address - Street 2:
Practice Address - City:LAKESIDE PARK
Practice Address - State:KY
Practice Address - Zip Code:41017-3195
Practice Address - Country:US
Practice Address - Phone:859-446-6263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH.023697363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily