Provider Demographics
NPI:1861272510
Name:MEDEIROS, JACQUELINE (LAC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MEDEIROS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:JAC
Other - Middle Name:
Other - Last Name:MEDEIROS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC
Mailing Address - Street 1:161 OCEAN PARK BLVD APT C
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-3527
Mailing Address - Country:US
Mailing Address - Phone:760-780-2697
Mailing Address - Fax:
Practice Address - Street 1:3030 SAWTELLE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-1408
Practice Address - Country:US
Practice Address - Phone:310-390-9018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC19841171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist