Basic Information
| Provider Information | |||||||||
| NPI: | 1801025960 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACQUES | ||||||||
| FirstName: | CHANTAL | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 5712236780 | ||||||||
| Practice Location | |||||||||
| Address1: | 14337 NEWBROOK DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | CHANTILLY | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201514259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5715125990 | ||||||||
| FaxNumber: | 5715125989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2009 | ||||||||
| LastUpdateDate: | 04/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2009016926 | MO | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 046.010234 | IL | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 0618002953 | VA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.