Provider Demographics
NPI:1861725228
Name:JACQUEZ, VICENTE (NP-C)
Entity type:Individual
Prefix:
First Name:VICENTE
Middle Name:
Last Name:JACQUEZ
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 LORRAINE LN
Mailing Address - Street 2:
Mailing Address - City:CHAPARRAL
Mailing Address - State:NM
Mailing Address - Zip Code:88081-7435
Mailing Address - Country:US
Mailing Address - Phone:915-497-4645
Mailing Address - Fax:
Practice Address - Street 1:6065 MONTANA AVE
Practice Address - Street 2:SUITE A-2
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-1835
Practice Address - Country:US
Practice Address - Phone:915-771-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1105363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily