Provider Demographics
NPI:1568960805
Name:ROMAN, JACQUELINE (DAOM, LAC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:ROMAN
Suffix:
Gender:F
Credentials:DAOM, LAC
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:ROMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4 WALNUT HILL RD
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-4716
Mailing Address - Country:US
Mailing Address - Phone:845-656-0694
Mailing Address - Fax:
Practice Address - Street 1:544 MAIN ST
Practice Address - Street 2:
Practice Address - City:BEACON
Practice Address - State:NY
Practice Address - Zip Code:12508-2861
Practice Address - Country:US
Practice Address - Phone:845-656-0694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003002171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist