MEDICARE: JOHN C JAQUES P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	001966	GA

General Provider Information

NPI Number	:	1073581435
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN C JAQUES P.A.

Provider Business Mailing Address
First Line	:	3525 PIEDMONT ROAD NE
Second Line	:	#7-601
City	:	ATLANTA
State	:	GA
Zip	:	30305-7041
Country	:	US
Telephone Number	:	404-842-5425
Fax Number	:

Provider Business Practice Location Address
First Line	:	2335 LIMESTONE OVERLOOK
Second Line	:
City	:	GAINESVILLE
State	:	GA
Zip	:	30501-7443
Country	:	US
Telephone Number	:	770-297-0356
Fax Number	:	770-297-7564

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2006
Last Update Date	:	01/26/2012

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