Provider Demographics
NPI:1881647709
Name:JACQUES, THERESA M (FNP-C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:JACQUES
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:NORTH VASSALBORO
Mailing Address - State:ME
Mailing Address - Zip Code:04962-0247
Mailing Address - Country:US
Mailing Address - Phone:207-873-1098
Mailing Address - Fax:207-873-4514
Practice Address - Street 1:80 GARLAND RD
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:ME
Practice Address - Zip Code:04901-0600
Practice Address - Country:US
Practice Address - Phone:207-873-1098
Practice Address - Fax:207-873-4514
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER023315363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
01-0443255OtherCIGNA
ME283350099Medicaid
ME098281OtherANTHEM
500006987OtherRAILROAD MEDICARE
01-0443255OtherCIGNA
500006987OtherRAILROAD MEDICARE