Basic Information
| Provider Information | |||||||||
| NPI: | 1194172726 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACQUES | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | RN-BC,AGPCNP-BC,CMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11350 MCCORMICK RD | ||||||||
| Address2: | BLDG 1, SUITE 501 | ||||||||
| City: | HUNT VALLEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103291071 | ||||||||
| FaxNumber: | 4103291054 | ||||||||
| Practice Location | |||||||||
| Address1: | 8501 ARLINGTON BLVD STE 410 | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037384331 | ||||||||
| FaxNumber: | 7036421876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2016 | ||||||||
| LastUpdateDate: | 04/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 0019005354 | VA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | 363LA2200X | 0024173383 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | 0024173383 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363L00000X | 0024173383 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.