Provider Demographics
NPI:1780702811
Name:JACQUES, MARK LAWRENCE (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:LAWRENCE
Last Name:JACQUES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 MEDICAL CENTER ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT CAVAZOS
Mailing Address - State:TX
Mailing Address - Zip Code:76544
Mailing Address - Country:US
Mailing Address - Phone:254-553-6228
Mailing Address - Fax:
Practice Address - Street 1:590 MEDICAL CENTER ROAD
Practice Address - Street 2:
Practice Address - City:FORT CAVAZOS
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-553-6228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2191942083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine