Provider Demographics
NPI:1679681837
Name:JACQUES, DANA R (MD)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:R
Last Name:JACQUES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1735 CREEKSIDE DR
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3914
Practice Address - Country:US
Practice Address - Phone:916-983-3500
Practice Address - Fax:916-983-8437
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG88578207V00000X, 207V00000X
WI42315207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34007300Medicaid
WI34007300Medicaid
CAD1018ZMedicare PIN
WI000338245Medicare ID - Type Unspecified