Provider Demographics
NPI:1861529505
Name:AMOLE, JACQUES HOWARD (DNP, APRN)
Entity type:Individual
Prefix:DR
First Name:JACQUES
Middle Name:HOWARD
Last Name:AMOLE
Suffix:
Gender:M
Credentials:DNP, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2810
Mailing Address - Country:US
Mailing Address - Phone:386-236-3200
Mailing Address - Fax:
Practice Address - Street 1:200 SAN SEBASTIAN WAY
Practice Address - Street 2:
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084
Practice Address - Country:US
Practice Address - Phone:904-209-6234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1084092363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health