Provider Demographics
NPI:1902370349
Name:DWAYNE ST. JACQUES MD PLLC
Entity Type:Organization
Organization Name:DWAYNE ST. JACQUES MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:ST. JACQUES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-783-8964
Mailing Address - Street 1:15215 SOUTH 48TH STREET
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-9375
Mailing Address - Country:US
Mailing Address - Phone:480-783-8964
Mailing Address - Fax:480-783-8967
Practice Address - Street 1:15215 SOUTH 48TH STREET
Practice Address - Street 2:SUITE 110
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-9375
Practice Address - Country:US
Practice Address - Phone:480-783-8964
Practice Address - Fax:480-783-8967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ424052Medicaid