Basic Information
| Provider Information | |||||||||
| NPI: | 1154779551 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Credential: | MS, LAT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 OCHSNER BLVD | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704338107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858752828 | ||||||||
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| Practice Location | |||||||||
| Address1: | 26301 LA-1088 | ||||||||
| Address2: | |||||||||
| City: | MANDEVILLE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856245046 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2016 | ||||||||
| LastUpdateDate: | 05/26/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | ATH.200450 | LA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.