Provider Demographics
NPI:1194838979
Name:JACQUES, JEANNINE (MSW)
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:
Last Name:JACQUES
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 GREENLEAF WOODS DR UNIT 201
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-5442
Mailing Address - Country:US
Mailing Address - Phone:603-433-7596
Mailing Address - Fax:
Practice Address - Street 1:5 GREENLEAF WOODS DR UNIT 201
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-5442
Practice Address - Country:US
Practice Address - Phone:603-433-7596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH80002912Medicaid
NH1407744Y0NH01OtherANTHEM BC/BS OF NH
NH80002912Medicaid