Provider Demographics
NPI:1245956713
Name:PRINCE, JACQUES
Entity type:Individual
Prefix:
First Name:JACQUES
Middle Name:
Last Name:PRINCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5430 85TH AVE APT 202
Mailing Address - Street 2:
Mailing Address - City:NEW CARROLLTON
Mailing Address - State:MD
Mailing Address - Zip Code:20784-3130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3001 BRANDENBURG RD NE
Practice Address - Street 2:APT 811
Practice Address - City:DISTRICT OF COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:20018-2001
Practice Address - Country:US
Practice Address - Phone:240-615-9883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant