Provider Demographics
NPI:1871041376
Name:JACQUES, ROSE MYRIAME (NP)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MYRIAME
Last Name:JACQUES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 WIMBLEDON SQ STE H
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4945
Mailing Address - Country:US
Mailing Address - Phone:757-410-8244
Mailing Address - Fax:
Practice Address - Street 1:109 WIMBLEDON SQ STE H
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4945
Practice Address - Country:US
Practice Address - Phone:757-410-8244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2023-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173718363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1871041376OtherMULTIPLAN
VA1871041376OtherOPTIMA HEALTH
VA1871041376Medicaid
VA1871041376OtherTRICARE/CHAMPUS
VA1871041376OtherVIRGINIA PREMIER HEALTH PLAN
VA1871041376OtherCORVEL
VA1871041376OtherHUMANA
NC1871041376Medicaid
VA1871041376OtherUSA MANAGED CARE
NC1871041376Medicaid