Healthcare Provider Details

I. General information

NPI: 1508830803
Provider Name (Legal Business Name): DWAYNE MICHAEL ST JACQUES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15215 S 48TH ST SUITE 110
PHOENIX AZ
85044-9142
US

IV. Provider business mailing address

15215 S 48TH ST SUITE 110
PHOENIX AZ
85044-9142
US

V. Phone/Fax

Practice location:
  • Phone: 480-783-8964
  • Fax: 480-783-8967
Mailing address:
  • Phone: 480-783-8964
  • Fax: 480-783-8967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number24143
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAZ24143
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: