Healthcare Provider Details

I. General information

NPI: 1598741423
Provider Name (Legal Business Name): JENNIFER MARIE DRAGOUN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 04/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 MARKET ST
PHILADELPHIA PA
19103-1400
US

IV. Provider business mailing address

134 SHELDRAKE DR
PAOLI PA
19301-1244
US

V. Phone/Fax

Practice location:
  • Phone: 215-241-3256
  • Fax:
Mailing address:
  • Phone: 610-695-4693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD072400L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: