Basic Information
| Provider Information | |||||||||
| NPI: | 1497049209 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAMPLAIN | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7011 RIBELIN RANCH DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787501574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123457436 | ||||||||
| FaxNumber: | 5124674363 | ||||||||
| Practice Location | |||||||||
| Address1: | 7011 RIBELIN RANCH DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787507875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123457436 | ||||||||
| FaxNumber: | 5123467436 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2011 | ||||||||
| LastUpdateDate: | 09/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036134052 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | R1713 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.