Provider Demographics
NPI:1134591977
Name:JACQUES, TRISTA
Entity type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:JACQUES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 E CHEROKEE AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-5323
Mailing Address - Country:US
Mailing Address - Phone:918-423-9400
Mailing Address - Fax:
Practice Address - Street 1:32 E CHEROKEE AVE STE 104
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5323
Practice Address - Country:US
Practice Address - Phone:918-423-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management