Provider Demographics
NPI:1265784938
Name:KOEKKOEK, JACKIE (MSOM, L AC, LMBT)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:KOEKKOEK
Suffix:
Gender:F
Credentials:MSOM, L AC, LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 MUSCADINE TRL
Mailing Address - Street 2:
Mailing Address - City:WALLACE
Mailing Address - State:NC
Mailing Address - Zip Code:28466-2365
Mailing Address - Country:US
Mailing Address - Phone:303-775-9908
Mailing Address - Fax:
Practice Address - Street 1:1105 NEW POINTE BLVD
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-4127
Practice Address - Country:US
Practice Address - Phone:303-775-9908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC639171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist