JACQUELINE M CHAMPLAIN Medical Doctor License verification

Business Entity

CANCELLED

License Type

Medical Doctor

Description

TEMPORARY MEDICAL PERMIT

License Number

125059551

License Status

CANCELLED

Business

First Name

JACQUELINE

Middle

Last Name

CHAMPLAIN

Business Name

JACQUELINE M CHAMPLAIN

Original Issue Date

07/01/2011

Effective Date

07/01/2011

Expiration Date

06/30/2014

City

HINSDALE

State

Zip

60521

County

DUPAGE

Specialty/Qualifier

Family Medicine

Ever Disciplined

LastModifiedDate

05/25/2011