Provider Demographics
NPI:1720759798
Name:MOMPLAISIR, JACQUES NAZAIRE (RN)
Entity type:Individual
Prefix:
First Name:JACQUES
Middle Name:NAZAIRE
Last Name:MOMPLAISIR
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 JENSEN AVE
Mailing Address - Street 2:
Mailing Address - City:RAHWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07065-2219
Mailing Address - Country:US
Mailing Address - Phone:732-213-9519
Mailing Address - Fax:
Practice Address - Street 1:777 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3409
Practice Address - Country:US
Practice Address - Phone:718-667-2402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY798551163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY798551Medicaid