Provider Demographics
NPI:1275187957
Name:ST JACQUES, LAUREN (PT)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:ST JACQUES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 KESWICK CT
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22602-7807
Mailing Address - Country:US
Mailing Address - Phone:540-931-1265
Mailing Address - Fax:
Practice Address - Street 1:101 W 14TH ST
Practice Address - Street 2:
Practice Address - City:FRONT ROYAL
Practice Address - State:VA
Practice Address - Zip Code:22630-3607
Practice Address - Country:US
Practice Address - Phone:540-636-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001083225100000X, 2251G0304X
VA23050042202251G0304X
VA02305004220225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics