Provider Demographics
NPI:1922094259
Name:JACQUES, ROBERT L (ARNP)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:JACQUES
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 LAKELAND HILLS BLVD
Mailing Address - Street 2:ATTN: MANAGED CARE DEPT
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-4543
Mailing Address - Country:US
Mailing Address - Phone:863-687-1100
Mailing Address - Fax:863-630-6528
Practice Address - Street 1:130 PABLO ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-3818
Practice Address - Country:US
Practice Address - Phone:863-687-1259
Practice Address - Fax:863-284-1786
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP917588363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1497748743OtherGROUP NPI / LRHSI
FLDA5786OtherRAILROAD GROUP MEDICARE NUMBER / LRHSI
FLARNP917588OtherARNP FL LICENSE
FL306705000Medicaid
Q16707Medicare UPIN
FLQ16707Medicare UPIN
FLY054ZYMedicare PIN