Provider Demographics
NPI:1891828281
Name:LEBEAU, JACQUE P (MD)
Entity Type:Individual
Prefix:
First Name:JACQUE
Middle Name:P
Last Name:LEBEAU
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:P.O. BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:407-650-7129
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:5153 NORTH 9TH AVE.
Practice Address - Street 2:NEMOURS CHILDRENS CLINIC, PENSACOLA
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8785
Practice Address - Country:US
Practice Address - Phone:850-505-4735
Practice Address - Fax:850-505-4714
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2009009831207Y00000X
FLME105524207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1891828281Medicaid