Provider Demographics
NPI:1790531739
Name:JACQUES, LIBERTY (DNP, RN, ACNS-BC)
Entity type:Individual
Prefix:
First Name:LIBERTY
Middle Name:
Last Name:JACQUES
Suffix:
Gender:F
Credentials:DNP, RN, ACNS-BC
Other - Prefix:
Other - First Name:LIBERTY
Other - Middle Name:
Other - Last Name:DYKEHOUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 383492
Mailing Address - Street 2:
Mailing Address - City:WAIKOLOA
Mailing Address - State:HI
Mailing Address - Zip Code:96738-3492
Mailing Address - Country:US
Mailing Address - Phone:616-460-3769
Mailing Address - Fax:
Practice Address - Street 1:65-1267 KAWAIHAE RD
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-7345
Practice Address - Country:US
Practice Address - Phone:808-881-4745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704265974364SA2200X
HI105646364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Multi-Specialty