Provider Demographics
NPI:1477035442
Name:GULLEY, JACQUELINE M (DC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:GULLEY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10699 E 600TH ST
Mailing Address - Street 2:
Mailing Address - City:LYNN CENTER
Mailing Address - State:IL
Mailing Address - Zip Code:61262-9764
Mailing Address - Country:US
Mailing Address - Phone:309-714-5512
Mailing Address - Fax:
Practice Address - Street 1:2010 E 38TH ST STE 201B
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-1179
Practice Address - Country:US
Practice Address - Phone:309-714-5512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA079576111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor