=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073581435
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN C JAQUES P.A.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2006
-----------------------------------------------------
Last Update Date | 01/26/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2335 LIMESTONE OVERLOOK
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30501-7443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-297-0356
-----------------------------------------------------
Fax | 770-297-7564
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3525 PIEDMONT ROAD NE #7-601
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30305-7041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-842-5425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 001966
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------