Provider Demographics
NPI:1962175992
Name:JACQUES, MARIE FRITZA
Entity type:Individual
Prefix:
First Name:MARIE FRITZA
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 1:262 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-2129
Mailing Address - Country:US
Mailing Address - Phone:929-250-6691
Mailing Address - Fax:
Practice Address - Street 1:2101 41ST AVE
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-4801
Practice Address - Country:US
Practice Address - Phone:718-784-2240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11012574363LF0000X
NYF348937-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily