Provider Demographics
NPI:1376743468
Name:FELLMAN, JONATHAN SCOTT (LAC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:SCOTT
Last Name:FELLMAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-1107
Mailing Address - Country:US
Mailing Address - Phone:415-573-9151
Mailing Address - Fax:
Practice Address - Street 1:1807 MARKET ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-1107
Practice Address - Country:US
Practice Address - Phone:415-573-9151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8836171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist