Provider Demographics
NPI:1073016416
Name:WHITLOCK, JACQUELINE LACHALLE (LVN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:LACHALLE
Last Name:WHITLOCK
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 LARAMIE LN
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-5382
Mailing Address - Country:US
Mailing Address - Phone:972-805-3571
Mailing Address - Fax:
Practice Address - Street 1:204 LARAMIE LN
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-5382
Practice Address - Country:US
Practice Address - Phone:972-805-3571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207692164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse