Provider Demographics
NPI:1285773762
Name:COLEMAN, JACK F (LAC)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:F
Last Name:COLEMAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:69 WHITEHALL RD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-3245
Mailing Address - Country:US
Mailing Address - Phone:516-255-1757
Mailing Address - Fax:516-740-5860
Practice Address - Street 1:30 HEMPSTEAD AVE
Practice Address - Street 2:SUITE H7
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4033
Practice Address - Country:US
Practice Address - Phone:516-536-1249
Practice Address - Fax:516-252-9177
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001094171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist