Provider Demographics
NPI:1134627839
Name:GOJKOVICH, JACQUELINE SUE (LAC)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:SUE
Last Name:GOJKOVICH
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 1:50 CATALINA DR
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-1121
Mailing Address - Country:US
Mailing Address - Phone:805-607-7895
Mailing Address - Fax:
Practice Address - Street 1:701 E SANTA CLARA ST
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93001-5972
Practice Address - Country:US
Practice Address - Phone:805-607-7895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-28
Last Update Date:2018-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC15531171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist