Provider Demographics
NPI:1578922209
Name:WHALEN, JACLYN (LAC)
Entity Type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:
Last Name:WHALEN
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 1:14825 SE HARMON CT
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97267-1722
Mailing Address - Country:US
Mailing Address - Phone:208-791-9136
Mailing Address - Fax:
Practice Address - Street 1:1540 SE CLINTON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1130
Practice Address - Country:US
Practice Address - Phone:503-451-0895
Practice Address - Fax:503-974-0958
Is Sole Proprietor?:No
Enumeration Date:2016-02-23
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC176130171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist