Provider Demographics
NPI:1083940860
Name:LE PROVOST, JEAN-LUC II (ND)
Entity type:Individual
Prefix:DR
First Name:JEAN-LUC
Middle Name:
Last Name:LE PROVOST
Suffix:II
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 N 36TH ST UNIT 1058
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-5308
Mailing Address - Country:US
Mailing Address - Phone:602-377-3671
Mailing Address - Fax:
Practice Address - Street 1:1225 N 36TH ST UNIT 1058
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-5308
Practice Address - Country:US
Practice Address - Phone:602-377-3671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ09-1139175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath