Provider Demographics
NPI:1154891026
Name:DELLA JACONO, FRED PATRICK (AP,LMT)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:PATRICK
Last Name:DELLA JACONO
Suffix:
Gender:M
Credentials:AP,LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 NW 37TH WAY
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33066-2261
Mailing Address - Country:US
Mailing Address - Phone:954-488-3388
Mailing Address - Fax:
Practice Address - Street 1:3201 GRIFFIN RD STE 104
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-6900
Practice Address - Country:US
Practice Address - Phone:954-488-3008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-04
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL46183225700000X
FL4006171100000X
FL14560111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171100000XOther Service ProvidersAcupuncturist