Provider Demographics
NPI:1851563019
Name:JAQUES, NICOLE BEALL (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:BEALL
Last Name:JAQUES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BEALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:105 REDBUD DR
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-1673
Mailing Address - Country:US
Mailing Address - Phone:615-745-8150
Mailing Address - Fax:
Practice Address - Street 1:105 REDBUD DR
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-1673
Practice Address - Country:US
Practice Address - Phone:615-745-8150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN45895207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine