Provider Demographics
NPI:1073577524
Name:JACQUES, CHARLES HM (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:HM
Last Name:JACQUES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:DAWES
Mailing Address - State:WV
Mailing Address - Zip Code:25054-0070
Mailing Address - Country:US
Mailing Address - Phone:304-734-2040
Mailing Address - Fax:304-734-2047
Practice Address - Street 1:5722 CABIN CREEK RD
Practice Address - Street 2:
Practice Address - City:DAWES
Practice Address - State:WV
Practice Address - Zip Code:25054-0000
Practice Address - Country:US
Practice Address - Phone:304-595-5006
Practice Address - Fax:304-595-2054
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17181207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0053482000Medicaid
C34187Medicare UPIN