Provider Demographics
NPI:1144289240
Name:JACQUES, MICHAEL FRANCIS (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:FRANCIS
Last Name:JACQUES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:FRANCIS
Other - Last Name:JACQUES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:22 MILL ST
Mailing Address - Street 2:SUITE 004
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-4784
Mailing Address - Country:US
Mailing Address - Phone:781-646-0500
Mailing Address - Fax:781-646-7130
Practice Address - Street 1:22 MILL ST
Practice Address - Street 2:SUITE 004
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-4784
Practice Address - Country:US
Practice Address - Phone:781-646-0500
Practice Address - Fax:781-646-7130
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6212103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW04963Medicare ID - Type Unspecified