Provider Demographics
NPI:1710423850
Name:JAQUESS, JESSICA DAWN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:DAWN
Last Name:JAQUESS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1391 GROVE DR
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101
Mailing Address - Country:US
Mailing Address - Phone:575-703-5281
Mailing Address - Fax:
Practice Address - Street 1:1391 GROVE DR
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-1110
Practice Address - Country:US
Practice Address - Phone:575-703-5281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1629225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant