Provider Demographics
NPI:1104890656
Name:JACQUES, PETE A (PA-C)
Entity type:Individual
Prefix:
First Name:PETE
Middle Name:A
Last Name:JACQUES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1241
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98401-1241
Mailing Address - Country:US
Mailing Address - Phone:253-272-5127
Mailing Address - Fax:253-404-0506
Practice Address - Street 1:2202 S CEDAR ST
Practice Address - Street 2:STE. #310
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2318
Practice Address - Country:US
Practice Address - Phone:253-272-5127
Practice Address - Fax:253-404-0506
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10001731363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPA10001731OtherWA LICENSE
WAAB32890Medicare PIN
WAPA10001731OtherWA LICENSE