Provider Demographics
NPI:1245554336
Name:JAQUEZ, JEANETTE LOUISE (PTA)
Entity type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:LOUISE
Last Name:JAQUEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3180 N BUTLER AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2336
Mailing Address - Country:US
Mailing Address - Phone:505-320-4153
Mailing Address - Fax:
Practice Address - Street 1:3180 N BUTLER AVE STE 300
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2336
Practice Address - Country:US
Practice Address - Phone:505-320-4153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-0418174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist