Provider Demographics
NPI:1568050045
Name:JAQUES, KIMBERLEY JO (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:JO
Last Name:JAQUES
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10011 N POTTAWATOMIE RD
Mailing Address - Street 2:
Mailing Address - City:HARRAH
Mailing Address - State:OK
Mailing Address - Zip Code:73045-9038
Mailing Address - Country:US
Mailing Address - Phone:405-831-6480
Mailing Address - Fax:
Practice Address - Street 1:929 W OWEN K GARRIOTT RD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5439
Practice Address - Country:US
Practice Address - Phone:580-237-3151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-09
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD14441183500000X
OK11822183500000X
MO43128183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO43128OtherSTATE BOARD OF PHARMACY
ARPD14441OtherSTATE BOARD OF PHARMACY
OK11822OtherSTATE BOARD OF PHARMACY LICENSE