Provider Demographics
NPI:1710049101
Name:JACQUIN, KIMBERLY ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ANN
Last Name:JACQUIN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 148
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:MO
Mailing Address - Zip Code:63084-0148
Mailing Address - Country:US
Mailing Address - Phone:636-583-1380
Mailing Address - Fax:636-583-1588
Practice Address - Street 1:118 UNION PLAZA DRIVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:MO
Practice Address - Zip Code:63084
Practice Address - Country:US
Practice Address - Phone:636-583-1380
Practice Address - Fax:636-583-1588
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003011572111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO177965OtherBLUE CROSS BLUE SHIELD
MOP00121266OtherRAILROAD MEDICARE PIN
MO117965OtherBLUE CROSS PIN
MO186599OtherCARPENTERS
MO186599OtherGHP
MO541250OtherHEALTHLINK
MO656115OtherUNITED HEALTHCARE
MO186599OtherGHP
MO117965OtherBLUE CROSS PIN