Provider Demographics
NPI:1548740533
Name:BACON, JAELLE TAMARA (DC)
Entity Type:Individual
Prefix:
First Name:JAELLE
Middle Name:TAMARA
Last Name:BACON
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 1:2625 DELAWARE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14216-1705
Mailing Address - Country:US
Mailing Address - Phone:716-335-9711
Mailing Address - Fax:
Practice Address - Street 1:2625 DELAWARE AVE STE 102
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14216-1705
Practice Address - Country:US
Practice Address - Phone:716-335-9711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-19
Last Update Date:2018-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013139111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor