Provider Demographics
NPI:1740280460
Name:LEGRAND, JACQUELINE JEAN (DO)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:JEAN
Last Name:LEGRAND
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1570 FRUITVILLE PIKE
Mailing Address - Street 2:STE 100
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-4056
Mailing Address - Country:US
Mailing Address - Phone:717-569-6481
Mailing Address - Fax:717-569-5213
Practice Address - Street 1:1570 FRUITVILLE PIKE
Practice Address - Street 2:STE 100
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-4056
Practice Address - Country:US
Practice Address - Phone:717-569-6481
Practice Address - Fax:717-569-5213
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0S007660L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015110240001Medicaid
PA0015110240001Medicaid