Provider Demographics
NPI:1548821234
Name:JACQUES, TINA (RN)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:JACQUES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 CARRINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:MA
Mailing Address - Zip Code:01050-9789
Mailing Address - Country:US
Mailing Address - Phone:413-862-4030
Mailing Address - Fax:
Practice Address - Street 1:132 CARRINGTON RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:MA
Practice Address - Zip Code:01050-9789
Practice Address - Country:US
Practice Address - Phone:413-374-2592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN200077363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health