Provider Demographics
NPI:1235595695
Name:JACQUES, REBECCA (RN)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:
Last Name:JACQUES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5783 NW BELWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-4162
Mailing Address - Country:US
Mailing Address - Phone:772-361-3854
Mailing Address - Fax:
Practice Address - Street 1:5783 NW BELWOOD CIR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-4162
Practice Address - Country:US
Practice Address - Phone:772-361-3854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9345557163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008309700Medicaid