Provider Demographics
NPI:1215002779
Name:JAQUEZ, JANIS A (PA)
Entity Type:Individual
Prefix:
First Name:JANIS
Middle Name:A
Last Name:JAQUEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 PARK RD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1853
Mailing Address - Country:US
Mailing Address - Phone:860-218-1725
Mailing Address - Fax:860-218-1727
Practice Address - Street 1:74 PARK RD
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1853
Practice Address - Country:US
Practice Address - Phone:860-218-1725
Practice Address - Fax:860-218-1727
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001743363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001743OtherLIC NUMBER
CT001743OtherLIC NUMBER