Provider Demographics
NPI:1558162933
Name:JAQUEZ, NANCY
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:JAQUEZ
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 1:7113 ANDERSONS FORGE PL
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-7462
Mailing Address - Country:US
Mailing Address - Phone:646-427-7061
Mailing Address - Fax:
Practice Address - Street 1:7113 ANDERSONS FORGE PL
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23225-7462
Practice Address - Country:US
Practice Address - Phone:646-427-7061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-21
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA526215172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver