Provider Demographics
NPI:1982153540
Name:JACQUES, TYMBER
Entity Type:Individual
Prefix:
First Name:TYMBER
Middle Name:
Last Name: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 1:301 E AVENUE B
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOPE
Mailing Address - State:KS
Mailing Address - Zip Code:67108-8808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 W BLANCHARD AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67505-1526
Practice Address - Country:US
Practice Address - Phone:620-663-7175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-01154224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant