Provider Demographics
NPI:1295214690
Name:MCKILLIP, JOLEEN MARIE (LAC)
Entity Type:Individual
Prefix:
First Name:JOLEEN
Middle Name:MARIE
Last Name:MCKILLIP
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 1:1834 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-1516
Mailing Address - Country:US
Mailing Address - Phone:510-845-1100
Mailing Address - Fax:
Practice Address - Street 1:1834 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703-1516
Practice Address - Country:US
Practice Address - Phone:510-845-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17323171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist