Healthcare Provider Details

I. General information

NPI: 1144289687
Provider Name (Legal Business Name): DENISE M JACQUES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 02/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PATEWOOD DR SUITE A120
GREENVILLE SC
29615-3593
US

IV. Provider business mailing address

7 INDEPENDENCE PT SUITE 140
GREENVILLE SC
29615-4566
US

V. Phone/Fax

Practice location:
  • Phone: 864-454-2670
  • Fax:
Mailing address:
  • Phone: 864-797-6044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number22187
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: