Provider Demographics
NPI:1417491408
Name:JACQUES, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:JACQUES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6827 N HIGH ST STE 121
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-2517
Mailing Address - Country:US
Mailing Address - Phone:614-849-2174
Mailing Address - Fax:
Practice Address - Street 1:6827 N HIGH ST STE 121
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-2517
Practice Address - Country:US
Practice Address - Phone:614-642-3180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-09
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH81-3875568OtherMARIN'S HOPE COUNSELING