Provider Demographics
NPI:1952999617
Name:ST. JACQUES, MICHAELIA L
Entity Type:Individual
Prefix:
First Name:MICHAELIA
Middle Name:L
Last Name:ST. JACQUES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-5004
Mailing Address - Country:US
Mailing Address - Phone:413-672-8489
Mailing Address - Fax:
Practice Address - Street 1:375 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:MA
Practice Address - Zip Code:01267-2610
Practice Address - Country:US
Practice Address - Phone:413-672-8489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA968567225X00000X
VT072.0100422225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist