Provider Demographics
NPI:1477528974
Name:JACQUES, RENALDO A (MD)
Entity Type:Individual
Prefix:DR
First Name:RENALDO
Middle Name:A
Last Name:JACQUES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 W. GARDEN STREET
Mailing Address - Street 2:HEARTLAND COMMUNITY HEALTH CLINIC
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61605-3531
Mailing Address - Country:US
Mailing Address - Phone:309-680-7600
Mailing Address - Fax:309-676-5506
Practice Address - Street 1:2321 N WISCONSIN AVENUE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3172
Practice Address - Country:US
Practice Address - Phone:309-680-7600
Practice Address - Fax:309-676-5506
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081670207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036081670Medicaid
IL036081670Medicaid
ILF56538Medicare UPIN