Provider Demographics
NPI:1336418623
Name:POULOS, JACQUELINE ROCHELLE (NMD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:ROCHELLE
Last Name:POULOS
Suffix:
Gender:F
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 N SAN FRANCISCO ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3260
Mailing Address - Country:US
Mailing Address - Phone:928-774-1332
Mailing Address - Fax:928-774-0042
Practice Address - Street 1:1100 N SAN FRANCISCO ST
Practice Address - Street 2:SUITE A
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3260
Practice Address - Country:US
Practice Address - Phone:928-774-1332
Practice Address - Fax:928-774-0042
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-15
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11-1272175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath