Provider Demographics
NPI:1659353894
Name:JACQUES, SUSAN DIANA (MS N APRN)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:DIANA
Last Name:JACQUES
Suffix:
Gender:F
Credentials:MS N APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 WEST SHORE ROAD
Mailing Address - Street 2:
Mailing Address - City:SOUTH HERO
Mailing Address - State:VT
Mailing Address - Zip Code:05486
Mailing Address - Country:US
Mailing Address - Phone:802-324-5122
Mailing Address - Fax:802-654-2699
Practice Address - Street 1:1 WINOOSKI PARK SMC BOX 259
Practice Address - Street 2:SAINT MICHAEL'S COLLEGE
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05439-0001
Practice Address - Country:US
Practice Address - Phone:802-654-2234
Practice Address - Fax:802-654-2699
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0020757363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner