Provider Demographics
NPI:1184941072
Name:JAQUES, CORY DANIEL (MD)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:DANIEL
Last Name:JAQUES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 WESTWOOD PLZ
Mailing Address - Street 2:UCLA PSYCHIATRY RES ED OFFICE
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 S AKERS ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-8311
Practice Address - Country:US
Practice Address - Phone:559-624-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-01
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1189142084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program