Provider Demographics
NPI:1750704854
Name:JACOBS, HOLLY (APRN)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:JACOBS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:AGUILAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:215 W 81ST TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-2334
Mailing Address - Country:US
Mailing Address - Phone:913-961-1695
Mailing Address - Fax:
Practice Address - Street 1:7900 LEES SUMMIT RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64139-1236
Practice Address - Country:US
Practice Address - Phone:816-404-7500
Practice Address - Fax:816-404-7514
Is Sole Proprietor?:No
Enumeration Date:2014-01-24
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014000951363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420016176Medicaid