Provider Demographics
NPI:1558825489
Name:HARDISON, JERRELL JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:JERRELL
Middle Name:JOHN
Last Name:HARDISON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 CRAIGHEAD ST APT D
Mailing Address - Street 2:
Mailing Address - City:CANONSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15317-1746
Mailing Address - Country:US
Mailing Address - Phone:814-244-1009
Mailing Address - Fax:
Practice Address - Street 1:9000 PERRY HWY
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15237-5367
Practice Address - Country:US
Practice Address - Phone:412-367-2165
Practice Address - Fax:412-367-2183
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC011451111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor