Provider Demographics
NPI:1083639967
Name:JACQUES, JODI BETH (MS)
Entity Type:Individual
Prefix:MS
First Name:JODI
Middle Name:BETH
Last Name:JACQUES
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MCCHESNEY AVE EXT
Mailing Address - Street 2:4-10
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-8801
Mailing Address - Country:US
Mailing Address - Phone:518-225-4215
Mailing Address - Fax:
Practice Address - Street 1:11-21 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-3968
Practice Address - Country:US
Practice Address - Phone:518-725-4310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor