Individual
KIMBERLEY JO JAQUES
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PHARMACIST
Contact information
Practice address
929 W OWEN K GARRIOTT RD, ENID, OK 73701-5439
(580) 237-3151
Mailing address
10011 N POTTAWATOMIE RD, HARRAH, OK 73045-9038
(405) 831-6480
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
11822
OK
183500000X
Pharmacist
43128
MO
183500000X
Pharmacist
PD14441
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
11822
STATE BOARD OF PHARMACY LICENSE
OK
01
—
43128
STATE BOARD OF PHARMACY
MO
01
—
PD14441
STATE BOARD OF PHARMACY
AR
Enumeration date
01/09/2021
Last updated
01/09/2021
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