Provider Demographics
NPI:1376082487
Name:JACQUES, AMANDA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:JACQUES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 MAPLE ST STE 202
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48763-9352
Mailing Address - Country:US
Mailing Address - Phone:989-362-6108
Mailing Address - Fax:989-362-0161
Practice Address - Street 1:295 MAPLE ST STE 202
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-9352
Practice Address - Country:US
Practice Address - Phone:989-362-6108
Practice Address - Fax:989-362-0161
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-22
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704276177363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner