Provider Demographics
NPI:1982198982
Name:JACQUOT, KERENA LUANN
Entity Type:Individual
Prefix:MRS
First Name:KERENA
Middle Name:LUANN
Last Name:JACQUOT
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 1:68 FIVE FINGER PEAKS RD
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-9196
Mailing Address - Country:US
Mailing Address - Phone:307-660-2134
Mailing Address - Fax:
Practice Address - Street 1:68 FIVE FINGER PEAKS RD
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-9196
Practice Address - Country:US
Practice Address - Phone:307-660-2134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator