Provider Demographics
NPI:1801025960
Name:JACQUES, CHANTAL H (OD)
Entity Type:Individual
Prefix:DR
First Name:CHANTAL
Middle Name:H
Last Name:JACQUES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:14337 NEWBROOK DR STE 400
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-4259
Practice Address - Country:US
Practice Address - Phone:571-512-5990
Practice Address - Fax:571-512-5989
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009016926152W00000X
IL046.010234152W00000X
VA0618002953152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
A01923OtherAETNA
1801025960OtherNPI NUMBER
IL202112003Medicare PIN
MO1801025960Medicaid
IL046010234Medicaid
A04536OtherHEALTHLINK
102663OtherEYEMED
MO172200006Medicare PIN
371265227OtherUNITED HEALTHCARE
IL202112003OtherMEDICARE PART B
1801025960OtherMERCY HEALTH PLAN
MO172200006OtherMEDICARE PART B
MO000000651653OtherANTHEM BLUE CROSS BLUE SHIELD OF MO
1801025960OtherGROUP HEALTH PLAN - GHP