Provider Demographics
NPI:1659461168
Name:JAQUES, AJ (OTRL)
Entity Type:Individual
Prefix:MS
First Name:AJ
Middle Name:
Last Name:JAQUES
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4434 E 400 N
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5525
Mailing Address - Country:US
Mailing Address - Phone:208-745-9046
Mailing Address - Fax:
Practice Address - Street 1:510 E 17TH ST # 400
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6154
Practice Address - Country:US
Practice Address - Phone:208-589-0807
Practice Address - Fax:208-542-9577
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-282225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist