Healthcare Provider Details

I. General information

NPI: 1306135462
Provider Name (Legal Business Name): JACQUES DOMINIC DUBOIS R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2011
Last Update Date: 03/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 BRIMHALL ST
SAINT PAUL MN
55105-2430
US

IV. Provider business mailing address

308 BRIMHALL ST
SAINT PAUL MN
55105-2430
US

V. Phone/Fax

Practice location:
  • Phone: 651-698-8115
  • Fax:
Mailing address:
  • Phone: 651-698-8115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number188706-0
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: