Provider Demographics
NPI:1861997496
Name:JACQUES, BRIAN D
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:JACQUES
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 1:299 BLACKWATER RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03867-4615
Mailing Address - Country:US
Mailing Address - Phone:603-973-9577
Mailing Address - Fax:
Practice Address - Street 1:60 MIDDLE RD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-4146
Practice Address - Country:US
Practice Address - Phone:603-743-4110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0718225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant