Provider Demographics
NPI:1407019441
Name:JACQUES, BETH ANN (AUD, CCC-A)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:ANN
Last Name:JACQUES
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PILLSBURY ST
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-3556
Mailing Address - Country:US
Mailing Address - Phone:603-856-8275
Mailing Address - Fax:603-219-0454
Practice Address - Street 1:1 PILLSBURY ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-3556
Practice Address - Country:US
Practice Address - Phone:603-856-8275
Practice Address - Fax:603-219-0454
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHA598237600000X
VT$$$$$$$$$237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3102544Medicaid
VT1015240Medicaid