Provider Demographics
NPI:1629035183
Name:ST. JACQUES, JAYSON R (MD)
Entity Type:Individual
Prefix:DR
First Name:JAYSON
Middle Name:R
Last Name:ST. 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 1:291 MOODY ST
Mailing Address - Street 2:PDI, INC, C/O MCKESSON
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-1246
Mailing Address - Country:US
Mailing Address - Phone:413-755-2006
Mailing Address - Fax:770-666-9450
Practice Address - Street 1:271 CAREW ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-2377
Practice Address - Country:US
Practice Address - Phone:413-748-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212693207U00000X, 207UN0902X, 2085N0904X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAH88284Medicare UPIN
MAA35420Medicare ID - Type Unspecified