Provider Demographics
NPI:1285330258
Name:JACQUES, STACI (MED)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:JACQUES
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4312 WILLOW RUN
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-1983
Mailing Address - Country:US
Mailing Address - Phone:580-628-1628
Mailing Address - Fax:
Practice Address - Street 1:4312 WILLOW RUN
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-1983
Practice Address - Country:US
Practice Address - Phone:580-628-1628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator