Basic Information
| Provider Information | |||||||||
| NPI: | 1073577524 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACQUES | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | H.M. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 70 | ||||||||
| Address2: | |||||||||
| City: | DAWES | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250540070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047342040 | ||||||||
| FaxNumber: | 3047342047 | ||||||||
| Practice Location | |||||||||
| Address1: | 5722 CABIN CREEK RD | ||||||||
| Address2: | |||||||||
| City: | DAWES | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250540000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045955006 | ||||||||
| FaxNumber: | 3045952054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 05/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 17181 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0053482000 | 05 | WV | MEDICAID |