Provider Demographics
NPI:1326781428
Name:SULLIVAN, JALEN
Entity Type:Individual
Prefix:
First Name:JALEN
Middle Name:
Last Name:SULLIVAN
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 1:18 E PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:YEADON
Mailing Address - State:PA
Mailing Address - Zip Code:19050-2843
Mailing Address - Country:US
Mailing Address - Phone:267-736-0660
Mailing Address - Fax:
Practice Address - Street 1:3100 TELEGRAPH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3239
Practice Address - Country:US
Practice Address - Phone:800-671-6377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-16
Last Update Date:2022-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program