Provider Demographics
NPI:1730966581
Name:JAQUETTE, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:JAQUETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23321
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-4321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3555 N WILLIAMSBURG COUNTY HWY
Practice Address - Street 2:
Practice Address - City:CADES
Practice Address - State:SC
Practice Address - Zip Code:29518-3008
Practice Address - Country:US
Practice Address - Phone:843-210-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-13
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9118384363A00000X
PA1210384363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant