Basic Information
| Provider Information | |||||||||
| NPI: | 1679681837 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACQUES | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3400 DATA DR | ||||||||
| Address2: | PHYSICIAN SUPPORT SERVICES | ||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956707956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2110 PROFESSIONAL DR | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956613752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165362500 | ||||||||
| FaxNumber: | 9167803902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 08/04/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 42315 | WI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207VX0000X | 42315 | WI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics | 207V00000X | G88578 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 34007300 | 05 | WI | MEDICAID |