Healthcare Provider Details

I. General information

NPI: 1780702811
Provider Name (Legal Business Name): MARK LAWRENCE JACQUES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 05/13/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 MEDICAL CENTER ROAD
FORT CAVAZOS TX
76544
US

IV. Provider business mailing address

590 MEDICAL CENTER ROAD
FORT CAVAZOS TX
76544
US

V. Phone/Fax

Practice location:
  • Phone: 254-553-6228
  • Fax:
Mailing address:
  • Phone: 254-553-6228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number219194
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: