Provider Demographics
NPI:1124154620
Name:CARLOCK, JACQUELINE MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MARIE
Last Name:CARLOCK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15531 127TH ST
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439
Mailing Address - Country:US
Mailing Address - Phone:630-243-9895
Mailing Address - Fax:630-257-2503
Practice Address - Street 1:15531 127TH ST
Practice Address - Street 2:
Practice Address - City:LEMONT
Practice Address - State:IL
Practice Address - Zip Code:60439
Practice Address - Country:US
Practice Address - Phone:630-243-9895
Practice Address - Fax:630-257-2503
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001633030OtherBLUE CROSS BLUE SHEILD
IL0001633030OtherBLUE CROSS BLUE SHEILD