Provider Demographics
NPI:1760691034
Name:ECKHOLM, JACQUELYN (LAC)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:ECKHOLM
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 1:711 SOUTH BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2926
Mailing Address - Country:US
Mailing Address - Phone:708-848-6190
Mailing Address - Fax:
Practice Address - Street 1:711 SOUTH BOULEVARD SUITE 4SUITE 4
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2926
Practice Address - Country:US
Practice Address - Phone:708-848-6190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist