Provider Demographics
NPI:1457585929
Name:JACQUEZ, TANYA ANNE (IDMT)
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:ANNE
Last Name:JACQUEZ
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 76 BOX 8415
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96319-0063
Mailing Address - Country:US
Mailing Address - Phone:573-774-8466
Mailing Address - Fax:
Practice Address - Street 1:PSC 76 BOX 8415
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96319-0063
Practice Address - Country:US
Practice Address - Phone:573-774-8466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians