Basic Information
| Provider Information | |||||||||
| NPI: | 1750704854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOBS | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AGUILAR | ||||||||
| OtherFirstName: | HOLLY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 215 W 81ST TER | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641142334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9139611695 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7900 LEES SUMMIT RD | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641391236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164047500 | ||||||||
| FaxNumber: | 8164047514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2014 | ||||||||
| LastUpdateDate: | 07/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2014000951 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 420016176 | 05 | MO | MEDICAID |