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General NPI Number Information
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NPI Number | 1073577524
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Entity Type | Individual
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Provider Name | CHARLES H.M. JACQUES M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/13/2006
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Last Update Date | 05/21/2020
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Provider Practice Location Address
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Address Line | 5722 CABIN CREEK RD
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City | DAWES
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State | WV
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Zip | 25054-0000
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Country | US
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Telephone | 304-595-5006
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Fax | 304-595-2054
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Provider Business Mailing Address
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Address Line | PO BOX 70
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City | DAWES
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State | WV
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Zip | 25054-0070
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Country | US
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Telephone | 304-734-2040
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Fax | 304-734-2047
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 17181
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License Number State | WV
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