Provider Demographics
NPI:1902850399
Name:MEAD-GOYETTE, JACQUELINE ANDREE (DC)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:ANDREE
Last Name:MEAD-GOYETTE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204
Mailing Address - Country:US
Mailing Address - Phone:209-944-5504
Mailing Address - Fax:209-467-7789
Practice Address - Street 1:3024 PACIFIC AVE.
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204
Practice Address - Country:US
Practice Address - Phone:209-944-5504
Practice Address - Fax:209-467-7789
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0246870111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10902850399Medicare UPIN
CADC0246870Medicare ID - Type Unspecified
CAV70675Medicare UPIN