Provider Demographics
NPI:1073581435
Name:JAQUES, JOHN C (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:JAQUES
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:3525 PIEDMONT ROAD NE
Mailing Address - Street 2:#7-601
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-7041
Mailing Address - Country:US
Mailing Address - Phone:404-842-5425
Mailing Address - Fax:
Practice Address - Street 1:2335 LIMESTONE OVERLOOK
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-7443
Practice Address - Country:US
Practice Address - Phone:770-297-0356
Practice Address - Fax:770-297-7564
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2012-01-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA001966363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ19090Medicare UPIN