Provider Demographics
NPI:1245470210
Name:JACQUES, KATHRYN ELIZABETH (MPT)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:ELIZABETH
Last Name:JACQUES
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 TUDOR CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5914
Mailing Address - Country:US
Mailing Address - Phone:907-729-3300
Mailing Address - Fax:
Practice Address - Street 1:CORNER OF ROUTE N12 AND N7
Practice Address - Street 2:
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-8132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-03
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPHYP2898225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist