Provider Demographics
NPI:1902034879
Name:JEANSONNE, SCOTT RYAN (DO)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:RYAN
Last Name:JEANSONNE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-3102
Mailing Address - Country:US
Mailing Address - Phone:505-861-1013
Mailing Address - Fax:505-224-8717
Practice Address - Street 1:120 S 9TH ST
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-3102
Practice Address - Country:US
Practice Address - Phone:505-861-1013
Practice Address - Fax:505-224-8717
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1580-10207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine