Provider Demographics
NPI:1891804498
Name:FONTAINE, JEAN H (DC)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:H
Last Name:FONTAINE
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 1:7205 RISING SUN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-3926
Mailing Address - Country:US
Mailing Address - Phone:215-276-2250
Mailing Address - Fax:215-276-2110
Practice Address - Street 1:7205 RISING SUN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-3926
Practice Address - Country:US
Practice Address - Phone:215-276-2250
Practice Address - Fax:215-276-2110
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1772111N00000X
PADC010306111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALU65407Medicare UPIN
AL000051821Medicare ID - Type Unspecified
ALU65407Medicare UPIN