Provider Demographics
NPI:1730710393
Name:JACQUE, MATTHEW MICHAEL
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MICHAEL
Last Name:JACQUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 MILLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48746-9538
Mailing Address - Country:US
Mailing Address - Phone:810-210-9502
Mailing Address - Fax:
Practice Address - Street 1:303 E KEARSLEY ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48502-1907
Practice Address - Country:US
Practice Address - Phone:810-762-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4704295616367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program