Healthcare Provider Details

I. General information

NPI: 1336335686
Provider Name (Legal Business Name): LAURA JACQUES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 SAVANNAH DR MERITER DEFOREST-WINDSOR
DEFOREST WI
53562
US

IV. Provider business mailing address

7974 UW HEALTH CT
MIDDLETON WI
53562-5531
US

V. Phone/Fax

Practice location:
  • Phone: 608-414-3300
  • Fax: 608-417-3100
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number55905
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: