Provider Demographics
NPI:1801156302
Name:JAYJACK, KIMBERLY A (ACNS)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:JAYJACK
Suffix:
Gender:F
Credentials:ACNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7214 JEFFREY ST
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-3511
Mailing Address - Country:US
Mailing Address - Phone:219-765-5207
Mailing Address - Fax:
Practice Address - Street 1:7214 JEFFREY ST
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375-3511
Practice Address - Country:US
Practice Address - Phone:219-865-9312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-18
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN280994705A163WC1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development