Basic Information
| Provider Information | |||||||||
| NPI: | 1013938471 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACQUE | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 354 BIRNIE AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011071108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137333470 | ||||||||
| FaxNumber: | 4137334298 | ||||||||
| Practice Location | |||||||||
| Address1: | 354 BIRNIE AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011071108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137333470 | ||||||||
| FaxNumber: | 4137334298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 05/13/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 125 | MA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | LD0146 | 01 | MA | BLUE CROSS | OTHER |