Provider Demographics
NPI:1629755947
Name:JAQUISH, JAYSON (PA-C)
Entity Type:Individual
Prefix:
First Name:JAYSON
Middle Name:
Last Name:JAQUISH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 LARKHAVEN LN
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-2949
Mailing Address - Country:US
Mailing Address - Phone:336-870-6381
Mailing Address - Fax:
Practice Address - Street 1:120 APPLECROSS RD STE 8
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8520
Practice Address - Country:US
Practice Address - Phone:910-692-8224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-13342207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine