Healthcare Provider Details

I. General information

NPI: 1073581435
Provider Name (Legal Business Name): JOHN C JAQUES P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 01/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2335 LIMESTONE OVERLOOK
GAINESVILLE GA
30501-7443
US

IV. Provider business mailing address

3525 PIEDMONT ROAD NE #7-601
ATLANTA GA
30305-7041
US

V. Phone/Fax

Practice location:
  • Phone: 770-297-0356
  • Fax: 770-297-7564
Mailing address:
  • Phone: 404-842-5425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001966
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: