Provider Demographics
NPI:1376322677
Name:FERGUSON, JALEN (DC)
Entity type:Individual
Prefix:MR
First Name:JALEN
Middle Name:
Last Name:FERGUSON
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 1:11345 PREAKNESS DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:TX
Mailing Address - Zip Code:75762-6313
Mailing Address - Country:US
Mailing Address - Phone:678-761-3497
Mailing Address - Fax:
Practice Address - Street 1:3526 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8707
Practice Address - Country:US
Practice Address - Phone:678-761-3497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104557937111NP0017X, 111NS0005X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician