Basic Information
| Provider Information | |||||||||
| NPI: | 1073599759 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JAQUES | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 GIBNER RD | ||||||||
| Address2: | DUNHAM US ARMY HEALTH CLINIC | ||||||||
| City: | CARLISLE BARRACKS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170135003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172453041 | ||||||||
| FaxNumber: | 7172453815 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 GIBNER RD | ||||||||
| Address2: | DUNHAM US ARMY HEALTH CLINIC | ||||||||
| City: | CARLISLE BARRACKS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170135003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172453041 | ||||||||
| FaxNumber: | 7172453815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | MA000014-L | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.