Healthcare Provider Details

I. General information

NPI: 1154779551
Provider Name (Legal Business Name): JONATHAN FERGUSON MS, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 05/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26301 LA-1088
MANDEVILLE LA
70448
US

IV. Provider business mailing address

1000 OCHSNER BLVD
COVINGTON LA
70433-8107
US

V. Phone/Fax

Practice location:
  • Phone: 985-624-5046
  • Fax:
Mailing address:
  • Phone: 985-875-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATH.200450
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: