Provider Demographics
NPI:1740024678
Name:ST JACQUES, KATHLEEN (FNP-BC)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:ST JACQUES
Suffix:
Gender:
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 THOMAS JOHNSON DR STE E
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4399
Mailing Address - Country:US
Mailing Address - Phone:301-694-3111
Mailing Address - Fax:
Practice Address - Street 1:63 THOMAS JOHNSON DR STE E
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4399
Practice Address - Country:US
Practice Address - Phone:301-694-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024190510363LF0000X
MDAC007237363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily