Provider Demographics
NPI:1861889743
Name:MARINO, JACQUELIN SUE (LAC)
Entity type:Individual
Prefix:
First Name:JACQUELIN
Middle Name:SUE
Last Name:MARINO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 N PACIFIC ST APT A
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-1952
Mailing Address - Country:US
Mailing Address - Phone:775-901-0558
Mailing Address - Fax:
Practice Address - Street 1:171 SAXONY RD STE 102
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-6776
Practice Address - Country:US
Practice Address - Phone:760-517-6306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-18
Last Update Date:2015-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14855171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist