Provider Demographics
NPI:1588319214
Name:JACQUES, JACKIE MARIE (PTA 16675171)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:MARIE
Last Name:JACQUES
Suffix:
Gender:F
Credentials:PTA 16675171
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 578
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-4309
Mailing Address - Country:US
Mailing Address - Phone:360-649-5596
Mailing Address - Fax:
Practice Address - Street 1:29804 HIGHWAY 101
Practice Address - Street 2:SUITE #5
Practice Address - City:QUILCENE
Practice Address - State:WA
Practice Address - Zip Code:98376
Practice Address - Country:US
Practice Address - Phone:360-765-0888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA16675171225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant