Basic Information
| Provider Information | |||||||||
| NPI: | 1881647709 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACQUES | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 247 | ||||||||
| Address2: | |||||||||
| City: | NORTH VASSALBORO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049620247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078731098 | ||||||||
| FaxNumber: | 2078734514 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 GARLAND RD | ||||||||
| Address2: | |||||||||
| City: | WINSLOW | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049010600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078731098 | ||||||||
| FaxNumber: | 2078734514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 05/05/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R023315 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 01-0443255 | 01 | CIGNA | OTHER | 283350099 | 05 | ME | MEDICAID | 098281 | 01 | ME | ANTHEM | OTHER | 500006987 | 01 | RAILROAD MEDICARE | OTHER |