Provider Demographics
NPI:1417772369
Name:JACQUES, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:JACQUES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 BORTHWICK AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-4102
Mailing Address - Country:US
Mailing Address - Phone:603-436-7171
Mailing Address - Fax:
Practice Address - Street 1:330 BORTHWICK AVE STE 101
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-4102
Practice Address - Country:US
Practice Address - Phone:603-436-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-16
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH082661-21363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily