Provider Demographics
NPI:1508918848
Name:JACQUES, ROBERT LEONARD (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEONARD
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 1:5419 S.W. SCHOLLS FERY ROAD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225
Mailing Address - Country:US
Mailing Address - Phone:503-241-8055
Mailing Address - Fax:
Practice Address - Street 1:400 9TH ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-7398
Practice Address - Country:US
Practice Address - Phone:541-997-8412
Practice Address - Fax:541-902-1320
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19329207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORA43679Medicare UPIN