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General NPI Number Information
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NPI Number | 1053369546
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Entity Type | Individual
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Provider Name | BRIAN P JACQUOT P.A.-C
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Gender | Male
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Dates
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Enumeration Date | 05/05/2006
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Last Update Date | 02/10/2025
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Provider Practice Location Address
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Address Line | 2300 N EDWARD ST SUITE 2350
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City | DECATUR
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State | IL
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Zip | 62526-4163
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Country | US
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Telephone | 217-876-2880
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Fax | 217-876-2885
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Provider Business Mailing Address
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Address Line | 2300 N EDWARD ST GSBLL
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City | DECATUR
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State | IL
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Zip | 62526-4163
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Country | US
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Telephone | 217-876-2857
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Fax | 217-876-2874
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 10004104A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 085001321
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License Number State | IL
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