Provider Demographics
NPI:1417096561
Name:DAGOSTINO, JEAN (DC)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:
Last Name:DAGOSTINO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1121
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18016-1121
Mailing Address - Country:US
Mailing Address - Phone:484-550-8506
Mailing Address - Fax:
Practice Address - Street 1:7613 TILGHMAN ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18106-9345
Practice Address - Country:US
Practice Address - Phone:610-395-6123
Practice Address - Fax:610-395-6474
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009169111N00000X, 111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA078361Medicare ID - Type Unspecified
PAU99594Medicare UPIN