Provider Demographics
NPI:1659482339
Name:JACQUEZ-DEAN, SUSAN M (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:JACQUEZ-DEAN
Suffix:
Gender:F
Credentials:MD
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1160 KEPLER DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-8321
Mailing Address - Country:US
Mailing Address - Phone:920-288-5630
Mailing Address - Fax:920-288-4539
Practice Address - Street 1:1160 KEPLER DR
Practice Address - Street 2:2ND FLOOR
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-8321
Practice Address - Country:US
Practice Address - Phone:920-288-5630
Practice Address - Fax:920-288-5439
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI45956-0202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34440300Medicaid