Provider Demographics
NPI:1144045899
Name:KIKOYO, JACKYLINE N (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JACKYLINE
Middle Name:N
Last Name:KIKOYO
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STURBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01566-1507
Mailing Address - Country:US
Mailing Address - Phone:774-240-6869
Mailing Address - Fax:
Practice Address - Street 1:58 MAIN ST
Practice Address - Street 2:
Practice Address - City:STURBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01566-1507
Practice Address - Country:US
Practice Address - Phone:774-240-6869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-18
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2319823363LP0808X
VA24193111363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health