MEDICARE: MS. JODI BETH JACQUES M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1083639967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JODI BETH JACQUES M.S.

Provider Business Mailing Address
First Line	:	400 MCCHESNEY AVE EXT
Second Line	:	4-10
City	:	TROY
State	:	NY
Zip	:	12180-8801
Country	:	US
Telephone Number	:	518-225-4215
Fax Number	:

Provider Business Practice Location Address
First Line	:	11-21 BROADWAY ST
Second Line	:
City	:	GLOVERSVILLE
State	:	NY
Zip	:	12078-3968
Country	:	US
Telephone Number	:	518-725-4310
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	07/08/2007

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