Healthcare Provider Details

I. General information

NPI: 1891914305
Provider Name (Legal Business Name): JERRY P JACQUES CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVENUE
BOSTON MA
02115
US

IV. Provider business mailing address

203 BIGELOW STREET APT 2
BRIGHTON MA
02135
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-7395
  • Fax: 617-730-0601
Mailing address:
  • Phone: 617-254-7953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5845
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: