Provider Demographics
NPI:1043456494
Name:CONNOLLY, JACQUELINE (DC)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:CONNOLLY
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 1:4712 ADMIRALTY WAY
Mailing Address - Street 2:179
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6905
Mailing Address - Country:US
Mailing Address - Phone:310-306-4828
Mailing Address - Fax:
Practice Address - Street 1:4560 ADMIRALTY WAY
Practice Address - Street 2:SUITE 252
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5423
Practice Address - Country:US
Practice Address - Phone:310-306-4828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30739111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor