Provider Demographics
NPI:1720076706
Name:JALLO, JACK I (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:I
Last Name:JALLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 WALNUT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:909 WALNUT ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5211
Practice Address - Country:US
Practice Address - Phone:215-955-7000
Practice Address - Fax:215-503-9170
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06897900207T00000X
PAMD048313L207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001634580Medicaid
NJ7226608Medicaid
PA393566Medicare PIN
NJ7226608Medicaid
PA001634580Medicaid
PA829843Medicare PIN