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General NPI Number Information
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NPI Number | 1568050045
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Entity Type | Individual
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Provider Name | KIMBERLEY JO JAQUES PHARMACIST
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Gender | Female
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Dates
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Enumeration Date | 01/09/2021
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Last Update Date | 01/09/2021
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Provider Practice Location Address
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Address Line | 929 W OWEN K GARRIOTT RD
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City | ENID
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State | OK
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Zip | 73701-5439
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Country | US
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Telephone | 580-237-3151
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Fax |
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Provider Business Mailing Address
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Address Line | 10011 N POTTAWATOMIE RD
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City | HARRAH
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State | OK
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Zip | 73045-9038
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Country | US
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Telephone | 405-831-6480
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | PD14441
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License Number State | AR
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 11822
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License Number State | OK
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Taxonomy #3
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 43128
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License Number State | MO
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