Provider Demographics
NPI:1013938471
Name:JACQUE, ANNE G (RD)
Entity Type:Individual
Prefix:MS
First Name:ANNE
Middle Name:G
Last Name:JACQUE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:354 BIRNIE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1108
Mailing Address - Country:US
Mailing Address - Phone:413-733-3470
Mailing Address - Fax:413-733-4298
Practice Address - Street 1:354 BIRNIE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1108
Practice Address - Country:US
Practice Address - Phone:413-733-3470
Practice Address - Fax:413-733-4298
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA125133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALD0146OtherBLUE CROSS
MAUX2361Medicare PIN