Provider Demographics
NPI:1295749943
Name:JACQUES, PAUL F (PA)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:F
Last Name:JACQUES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751137
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1137
Mailing Address - Country:US
Mailing Address - Phone:866-448-1641
Mailing Address - Fax:
Practice Address - Street 1:2233 NORTHWOODS BLVD
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405
Practice Address - Country:US
Practice Address - Phone:866-448-1641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
A857363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S96540Medicare UPIN