Provider Demographics
NPI:1225294820
Name:BOECK, JACQUELINE LAVON
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:LAVON
Last Name:BOECK
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:PAMELA
Other - Middle Name:KAY
Other - Last Name:HOLT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1031 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CUSHING
Mailing Address - State:OK
Mailing Address - Zip Code:74023-4503
Mailing Address - Country:US
Mailing Address - Phone:918-225-0031
Mailing Address - Fax:
Practice Address - Street 1:1031 E 5TH ST
Practice Address - Street 2:
Practice Address - City:CUSHING
Practice Address - State:OK
Practice Address - Zip Code:74023-4503
Practice Address - Country:US
Practice Address - Phone:918-225-0031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-03
Last Update Date:2008-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18002278P1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278P1004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedPulmonary Diagnostics