Basic Information
| Provider Information | |||||||||
| NPI: | 1245228485 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAQUISH | ||||||||
| FirstName: | KIM | ||||||||
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| Credential: | RNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 402319 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303842319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797097399 | ||||||||
| FaxNumber: | 4797097053 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 DODSON AVE | ||||||||
| Address2: | STE 125 | ||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729015182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795737960 | ||||||||
| FaxNumber: | 4795737961 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 08/27/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | P01373 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 155652741 | 05 | AR | MEDICAID | 100013980A | 05 | OK | MEDICAID |