Provider Demographics
NPI:1891057436
Name:NAKAMURA, JACQUELINE (LMT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:NAKAMURA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5809 HILLSIDE RD
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012-1827
Mailing Address - Country:US
Mailing Address - Phone:815-477-8546
Mailing Address - Fax:
Practice Address - Street 1:5809 HILLSIDE RD
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-1827
Practice Address - Country:US
Practice Address - Phone:815-477-8546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2227013631172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist