Provider Demographics
NPI:1194172726
Name:JACQUES, MICHELLE MARIE (RN-BC,AGPCNP-BC,CMT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:JACQUES
Suffix:
Gender:
Credentials:RN-BC,AGPCNP-BC,CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 EATON PL STE 312
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2208
Mailing Address - Country:US
Mailing Address - Phone:703-615-8422
Mailing Address - Fax:833-606-0558
Practice Address - Street 1:10400 EATON PL STE 312
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2208
Practice Address - Country:US
Practice Address - Phone:703-615-8422
Practice Address - Fax:833-606-0558
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019005354225700000X
VA0024173383363LA2200X, 363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology