Provider Demographics
NPI:1336335686
Name:JACQUES, LAURA (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:JACQUES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4200 SAVANNAH DR
Practice Address - Street 2:MERITER DEFOREST-WINDSOR
Practice Address - City:DEFOREST
Practice Address - State:WI
Practice Address - Zip Code:53562
Practice Address - Country:US
Practice Address - Phone:608-414-3300
Practice Address - Fax:608-417-3100
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55905207V00000X
WAML20008968207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1336335686Medicaid
WI1336335686Medicaid