Provider Demographics
NPI:1336420157
Name:JAQUES, JEREMY RYAN (DC)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:RYAN
Last Name:JAQUES
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1199 ASHBOROUGH DR SE
Mailing Address - Street 2:APT. B
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-6925
Mailing Address - Country:US
Mailing Address - Phone:678-947-3316
Mailing Address - Fax:678-947-3317
Practice Address - Street 1:6010 SOUTHARD TRCE
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-6343
Practice Address - Country:US
Practice Address - Phone:678-947-3316
Practice Address - Fax:678-947-3317
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008843111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor