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General NPI Number Information
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NPI Number | 1558329300
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Entity Type | Individual
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Provider Name | SHELLEY SUE JAQUISH M.D.
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Gender | Female
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Dates
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Enumeration Date | 05/02/2006
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Last Update Date | 04/24/2019
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Provider Practice Location Address
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Address Line | 6827 FIRST AVENUE SOUTH SUITE 100
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City | ST PETERSBURG
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State | FL
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Zip | 33707-4516
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Country | US
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Telephone | 727-341-0551
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Fax | 727-341-0332
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Provider Business Mailing Address
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Address Line | 10002 PRINCESS PALM AVE STE 332
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City | TAMPA
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State | FL
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Zip | 33619-8327
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Country | US
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Telephone | 813-571-7184
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Fax | 813-654-4695
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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 | 207YX0602X
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Taxonomy Name | Otolaryngic Allergy Physician
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License Number | ME82762
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | ME82762
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License Number State | FL
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