Provider Demographics
NPI:1255605267
Name:JACEK, HOLLY JEANETTE (CRNA)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:JEANETTE
Last Name:JACEK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:J
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4301 W MARKHAM ST # 783
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-7101
Mailing Address - Country:US
Mailing Address - Phone:501-686-7000
Mailing Address - Fax:501-526-5148
Practice Address - Street 1:4301 W MARKHAM ST # 515
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-686-6114
Practice Address - Fax:501-686-8139
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR73609163W00000X
ARC02918367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse