Healthcare Provider Details

I. General information

NPI: 1639360811
Provider Name (Legal Business Name): JAMIE LYNN JAQUA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 MADISON OAK DR
SAN ANTONIO TX
78258-3912
US

IV. Provider business mailing address

4535 DRESSLER RD NW
CANTON OH
44718-2545
US

V. Phone/Fax

Practice location:
  • Phone: 210-297-4050
  • Fax:
Mailing address:
  • Phone: 330-994-4731
  • Fax: 330-409-8898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberP6362
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberP6362
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number2010-01200
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: