Provider Demographics
NPI:1619266152
Name:JAQUES, JACKIE M
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:M
Last Name:JAQUES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 PLAZA TER
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-2449
Mailing Address - Country:US
Mailing Address - Phone:314-909-9809
Mailing Address - Fax:314-909-1388
Practice Address - Street 1:1008 PLAZA TER
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-2449
Practice Address - Country:US
Practice Address - Phone:314-909-9809
Practice Address - Fax:314-909-1388
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst