Active NPI
Dwayne Michael St Jacques, MD
- Pediatrics Physician
- Phoenix, AZ
National Provider Identifier
1508830803
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatrics Physician
- License
- AZ24143
- Practice address
- 15215 S 48TH St
Suite 110
Phoenix, AZ 85044-9142 - Phone
- (480) 783-8964
- Fax
- (480) 783-8967
- NPI assigned
- Feb 14, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Adolescent Medicine Physician | 2080A0000X | 24143 | AZ | |
| Pediatrics Physician | 208000000X | AZ24143 | AZ | Primary |
Addresses
Primary practice location
15215 S 48TH St
Suite 110
Phoenix, AZ 85044-9142
Mailing address
15215 S 48TH St
Suite 110
Phoenix, AZ 85044-9142
Phone (480) 783-8964
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 424052 | Medicaid | AZ |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| AZ24143 | AZ | MD | Pediatrics Physician |
| 24143 | AZ | MD | Pediatric Adolescent Medicine Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1139875200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1548115200000",
"number": "1508830803",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "15215 S 48TH ST",
"address_2": "SUITE 110",
"city": "PHOENIX",
"state": "AZ",
"postal_code": "850449142",
"telephone_number": "480-783-8964",
"fax_number": "480-783-8967"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "15215 S 48TH ST",
"address_2": "SUITE 110",
"city": "PHOENIX",
"state": "AZ",
"postal_code": "850449142",
"telephone_number": "480-783-8964",
"fax_number": "480-783-8967"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ST JACQUES",
"first_name": "DWAYNE",
"middle_name": "MICHAEL",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-02-14",
"last_updated": "2019-01-22",
"status": "A"
},
"taxonomies": [
{
"code": "2080A0000X",
"taxonomy_group": "",
"desc": "Pediatrics, Adolescent Medicine",
"state": "AZ",
"license": "24143",
"primary": false
},
{
"code": "208000000X",
"taxonomy_group": "",
"desc": "Pediatrics",
"state": "AZ",
"license": "AZ24143",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "424052",
"state": "AZ"
}
],
"endpoints": [],
"other_names": []
}Other providers in Phoenix, AZ
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- St Charles Place (st charles place III)
- St Cosmetics
- St Elizabeth Home Health Inc. (Palmeira Home Healthcare)
- Kari Lynn St Hubert, PA-C
- St James Long Term Care Pharmacy (St James LTC Pharmacy LLC)
- St Joseph Phar LLC
- St Josephs Pathology (Pathology Associates LTD)
- Bianca St Julian
- St Lukes Behavioral Hospital LP
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 22, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.