Provider Demographics
NPI:1063184554
Name:DETHMAN, JONAS
Entity type:Individual
Prefix:
First Name:JONAS
Middle Name:
Last Name:DETHMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 WINGED FOOT PL
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5265
Mailing Address - Country:US
Mailing Address - Phone:208-473-0493
Mailing Address - Fax:
Practice Address - Street 1:239 WINGED FOOT PL
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5265
Practice Address - Country:US
Practice Address - Phone:208-473-0493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-02
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide