Provider Demographics
NPI:1487167086
Name:JACKIE'S BEAUTY SUPPLY, LLC
Entity type:Organization
Organization Name:JACKIE'S BEAUTY SUPPLY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:541-423-7009
Mailing Address - Street 1:PO BOX 21112
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-0356
Mailing Address - Country:US
Mailing Address - Phone:541-423-7009
Mailing Address - Fax:
Practice Address - Street 1:485 ALEXANDER LOOP STE 110
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6753
Practice Address - Country:US
Practice Address - Phone:541-423-7009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-06
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19559225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty