NPIMap

Individual provider Active NPI

Fanny M Jaquez, MD

  • Neurology Physician
  • Sioux Falls, SD
National Provider Identifier
1740212208
Registry record updated Mar 25, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Neurology PhysicianTaxonomy code 2084N0400X
License
054903 Issued in GA
Practice address
1210 W 18TH St
Ste 100
Sioux Falls, SD 57104
Phone
(605) 312-8500
Fax
(605) 312-8501
NPI assigned
Jul 7, 2006
Last updated
Mar 25, 2022By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 25, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Neurology Physician 2084N0400X 054903 GA Primary

Addresses

Primary practice location

1210 W 18TH St
Ste 100
Sioux Falls, SD 57104

Mailing address

PO Box 5074
Sioux Falls, SD 57117-5074

Other practice location 1

11 Upper Riverdale Rd SW
Riverdale, GA 30274-2615
Phone (770) 897-7043

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address fjaquez6420@direct.sanfordhealth.org

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA, SD2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20040928000610 GA Practitioner - Neurology 1456341726 Reassigns benefits to 2 organizations
I20100604000563 SD Practitioner - Neurology 1456341726 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Neurology
Education
Other, 1985
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Tanner Medical Group IncGroup PAC ID 2769536143, 120 clinicians

Practice addresses (Care Compare)

690 Dallas Hwy
Suite 104
Villa Rica, GA 30180-1263
Phone (770) 812-3631

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
84.78 of 100Reported as group
Quality
78.77
Promoting interoperability
100
Improvement activities
40
Cost
70.49

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
17515ALMDPharmacist
054903GAMDNeurology Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Southern Regional Physicians Management Group, LLC CurrentSince Aug 1, 2018 Accepting new patients
Sanford Medical Center CurrentSince Feb 1, 2012 Accepting new patients
Sanford Clinic CurrentSince Mar 8, 2010 Accepting new patients
Sanford Clinic CurrentSince Mar 8, 2010 Accepting new patients
Sanford Clinic Current Accepting new patients
Tanner Medical Group Inc Neurology CurrentSince Feb 1, 2026 Accepting new patients

Locations

157 Clinic Ave
Ste 301
Carrollton, GA 30117
Phone (770) 812-3631

11 Upper Riverdale Rd SW
Riverdale, GA 30274
Phone (770) 897-7277

690 Dallas Hwy
Ste 104
Villa Rica, GA 30180
Phone (404) 778-8440

525 N Foster St
Mitchell, SD 57301
Phone (605) 995-2000

1210 W 18th St
Ste 100
Sioux Falls, SD 57104
Phone (605) 312-8500

1305 W 18th St
Sioux Falls, SD 57105
Phone (605) 312-7300

4405 E 26th St
Sioux Falls, SD 57103
Phone (605) 328-9000

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 4

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152230400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1648166400000",
    "number": "1740212208",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 5074",
            "city": "SIOUX FALLS",
            "state": "SD",
            "postal_code": "571175074"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1210 W 18TH ST",
            "address_2": "STE 100",
            "city": "SIOUX FALLS",
            "state": "SD",
            "postal_code": "57104",
            "telephone_number": "605-312-8500",
            "fax_number": "605-312-8501"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "11 Upper Riverdale Rd SW",
            "address_purpose": "LOCATION",
            "city": "Riverdale",
            "state": "GA",
            "postal_code": "302742615",
            "country_code": "US",
            "telephone_number": "770-897-7043",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "JAQUEZ",
        "first_name": "FANNY",
        "middle_name": "M",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-07-07",
        "last_updated": "2022-03-25",
        "certification_date": "2022-03-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2084N0400X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Neurology",
            "state": "GA",
            "license": "054903",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "fjaquez6420@direct.sanfordhealth.org",
            "affiliation": "N",
            "address_1": "1210 W 18th St",
            "address_2": "Ste 100",
            "city": "Sioux Falls",
            "state": "SD",
            "country_code": "US",
            "postal_code": "57104",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Sioux Falls, SD

Sources for this page

Verify at the official NPI Registry.