Provider Demographics
NPI:1730304296
Name:JACQUES, CARMELLE M II (LPN)
Entity Type:Individual
Prefix:
First Name:CARMELLE
Middle Name:M
Last Name:JACQUES
Suffix:II
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 AMANDA ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02346-2654
Mailing Address - Country:US
Mailing Address - Phone:617-838-6605
Mailing Address - Fax:
Practice Address - Street 1:30 SUMMER ST
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:MA
Practice Address - Zip Code:02343-1050
Practice Address - Country:US
Practice Address - Phone:781-767-2773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA60085164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0324388Medicaid