Provider Demographics
NPI:1790909794
Name:JAQUE, MARITZA VICTORIA (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARITZA
Middle Name:VICTORIA
Last Name:JAQUE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:KEARNY
Mailing Address - State:NJ
Mailing Address - Zip Code:07032-1662
Mailing Address - Country:US
Mailing Address - Phone:201-246-9762
Mailing Address - Fax:
Practice Address - Street 1:727 N BEERS ST
Practice Address - Street 2:
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-1514
Practice Address - Country:US
Practice Address - Phone:732-739-5955
Practice Address - Fax:732-888-7346
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00562400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist