Healthcare Provider Details

I. General information

NPI: 1740024678
Provider Name (Legal Business Name): KATHLEEN ST JACQUES FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 THOMAS JOHNSON DR STE E
FREDERICK MD
21702-4399
US

IV. Provider business mailing address

63 THOMAS JOHNSON DR STE E
FREDERICK MD
21702-4399
US

V. Phone/Fax

Practice location:
  • Phone: 301-694-7600
  • Fax:
Mailing address:
  • Phone: 301-694-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024190510
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAC007237
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: