Healthcare Provider Details

I. General information

NPI: 1891804498
Provider Name (Legal Business Name): JEAN H FONTAINE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 08/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7205 RISING SUN AVE
PHILADELPHIA PA
19111-3926
US

IV. Provider business mailing address

7205 RISING SUN AVE
PHILADELPHIA PA
19111-3926
US

V. Phone/Fax

Practice location:
  • Phone: 215-276-2250
  • Fax: 215-276-2110
Mailing address:
  • Phone: 215-276-2250
  • Fax: 215-276-2110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1772
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC010306
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: