Healthcare Provider Details

I. General information

NPI: 1609006592
Provider Name (Legal Business Name): THOMAS JOHN JACQUES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2009
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5771 N FRESNO ST
FRESNO CA
93710-6091
US

IV. Provider business mailing address

5771 N FRESNO ST
FRESNO CA
93710-6091
US

V. Phone/Fax

Practice location:
  • Phone: 595-272-1295
  • Fax: 559-369-7014
Mailing address:
  • Phone: 595-272-1295
  • Fax: 559-369-7014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA104289
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number13910
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: