MEDICARE: JANIS A. JAQUEZ PA

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	363AM0700X	Medical Physician Assistant	001743	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	001743	OTHER	CT	LIC NUMBER

General Provider Information

NPI Number	:	1215002779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANIS A. JAQUEZ PA

Provider Business Mailing Address
First Line	:	74 PARK RD
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06119-1853
Country	:	US
Telephone Number	:	860-218-1725
Fax Number	:	860-218-1727

Provider Business Practice Location Address
First Line	:	74 PARK RD
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06119-1853
Country	:	US
Telephone Number	:	860-218-1725
Fax Number	:	860-218-1727

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

Provider Enumeration Date	:	11/21/2006
Last Update Date	:	05/23/2012

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