Provider Demographics
NPI:1396282174
Name:JAQUES, MCKENNA ROSE
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:ROSE
Last Name:JAQUES
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MCKENNA
Other - Middle Name:ROSE
Other - Last Name:MINER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1525 SW SHIRLEY ANN DR
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-7665
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1525 SW SHIRLEY ANN DR
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-7665
Practice Address - Country:US
Practice Address - Phone:503-472-4055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health