Provider Demographics
NPI:1669990214
Name:VANDERBEKEN, JACLYN (LAC)
Entity type:Individual
Prefix:MRS
First Name:JACLYN
Middle Name:
Last Name:VANDERBEKEN
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 1:130 MAPLE AVENUE
Mailing Address - Street 2:BUILDING 9, SUITE 9
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 MAPLE AVENUE
Practice Address - Street 2:BUILDING 9, SUITE 9
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701
Practice Address - Country:US
Practice Address - Phone:732-889-9228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00126800171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist