Provider Demographics
NPI:1790033108
Name:TAYLOR, JAQUELYN LEIGH (LAC)
Entity Type:Individual
Prefix:MRS
First Name:JAQUELYN
Middle Name:LEIGH
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2501 W 103RD ST STE B05
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-1007
Mailing Address - Country:US
Mailing Address - Phone:773-905-2112
Mailing Address - Fax:
Practice Address - Street 1:2501 W 103RD ST STE B05
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-1007
Practice Address - Country:US
Practice Address - Phone:773-905-2112
Practice Address - Fax:312-313-6991
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198001093171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist