Provider Demographics
NPI:1871831735
Name:JACQUES, ISMAELE LING (APN-BC)
Entity Type:Individual
Prefix:
First Name:ISMAELE
Middle Name:LING
Last Name:JACQUES
Suffix:
Gender:F
Credentials:APN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 YORK ST
Mailing Address - Street 2:NP4-202
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-200-4822
Mailing Address - Fax:203-200-2099
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:NP4-202
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-200-4822
Practice Address - Fax:203-200-2099
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-27
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5195363L00000X
PASP012496363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner