Provider Demographics
NPI:1902168941
Name:JACQUES, DEBORAH R (DPT)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:R
Last Name:JACQUES
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 CANAL RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:NY
Mailing Address - Zip Code:13112-9799
Mailing Address - Country:US
Mailing Address - Phone:315-744-5145
Mailing Address - Fax:
Practice Address - Street 1:68 MAIN ST
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031
Practice Address - Country:US
Practice Address - Phone:315-744-5145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP84258208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation