Provider Demographics
NPI:1093217457
Name:JAMBON, DEREK MITCHELL
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:MITCHELL
Last Name:JAMBON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 FALCONER DR STE D
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-8211
Mailing Address - Country:US
Mailing Address - Phone:985-900-2305
Mailing Address - Fax:985-900-2306
Practice Address - Street 1:330 FALCONER DR STE D
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-8211
Practice Address - Country:US
Practice Address - Phone:985-900-2305
Practice Address - Fax:985-900-2306
Is Sole Proprietor?:No
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA09506225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant