Provider Demographics
NPI:1407998917
Name:CHAMPAGNE, JAIMIE DEBORAH (LICAC, MAOM)
Entity Type:Individual
Prefix:
First Name:JAIMIE
Middle Name:DEBORAH
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:LICAC, MAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 TEMPLE PL
Mailing Address - Street 2:SUITE 223
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1307
Mailing Address - Country:US
Mailing Address - Phone:617-733-4492
Mailing Address - Fax:617-728-4801
Practice Address - Street 1:59 TEMPLE PL
Practice Address - Street 2:SUITE 223
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1307
Practice Address - Country:US
Practice Address - Phone:617-733-4492
Practice Address - Fax:617-728-4801
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219522171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist