Provider Demographics
NPI:1144527557
Name:CAROLUS, JACKIE LEE (DC)
Entity type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:LEE
Last Name:CAROLUS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 592442
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78259-0172
Mailing Address - Country:US
Mailing Address - Phone:515-494-0966
Mailing Address - Fax:
Practice Address - Street 1:403 1ST AVE
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:IA
Practice Address - Zip Code:50220-1902
Practice Address - Country:US
Practice Address - Phone:515-465-3585
Practice Address - Fax:515-465-4651
Is Sole Proprietor?:No
Enumeration Date:2011-02-21
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5355111N00000X
IA007416111N00000X
246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB2212002OtherPTAN