Healthcare Provider Details

I. General information

NPI: 1336454990
Provider Name (Legal Business Name): JASON PAUL PELLEGRIN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2010
Last Update Date: 05/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 PHOSPHOR AVE
METAIRIE LA
70005-2727
US

IV. Provider business mailing address

714 PHOSPHOR AVE
METAIRIE LA
70005-2727
US

V. Phone/Fax

Practice location:
  • Phone: 504-224-8400
  • Fax: 504-272-0237
Mailing address:
  • Phone: 504-224-8400
  • Fax: 504-272-0237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1573
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: