Healthcare Provider Details

I. General information

NPI: 1720076706
Provider Name (Legal Business Name): JACK I JALLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 11/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 WALNUT ST 2ND FLOOR
PHILADELPHIA PA
19107-5211
US

IV. Provider business mailing address

909 WALNUT ST 2ND FLOOR
PHILADELPHIA PA
19107-5211
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-7000
  • Fax: 215-503-9170
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number25MA06897900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberMD048313L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: