Provider Demographics
NPI:1497049209
Name:CHAMPLAIN, JACQUELINE M (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:CHAMPLAIN
Suffix:
Gender:F
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1392 W US HIGHWAY 290
Mailing Address - Street 2:UNIT 2
Mailing Address - City:ELGIN
Mailing Address - State:TX
Mailing Address - Zip Code:78621
Mailing Address - Country:US
Mailing Address - Phone:512-285-3315
Mailing Address - Fax:512-281-2872
Practice Address - Street 1:1392 W US HIGHWAY 290
Practice Address - Street 2:UNIT 2
Practice Address - City:ELGIN
Practice Address - State:TX
Practice Address - Zip Code:78621
Practice Address - Country:US
Practice Address - Phone:512-285-3315
Practice Address - Fax:512-281-2872
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2023-12-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXR1713207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX562295YKXVMedicare PIN
TX562295YKXYMedicare PIN