Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | L-248654 | MA |
NPI | 1003102583 |
---|---|
Provider Name | Angela M. Jacques |
First Address | Boston, MA 02114 |
Second Address | Boston, MA 02114 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/06/2011 |
Last Update Date | 23/06/2011 |