Provider Demographics
NPI:1124836150
Name:DEDRICKSON, JAMES
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:DEDRICKSON
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 1:304 RIVERVIEW ST
Mailing Address - Street 2:
Mailing Address - City:LESHARA
Mailing Address - State:NE
Mailing Address - Zip Code:68064-1514
Mailing Address - Country:US
Mailing Address - Phone:402-320-2174
Mailing Address - Fax:
Practice Address - Street 1:1431 MAKERS ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521-3401
Practice Address - Country:US
Practice Address - Phone:402-320-2174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-23
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE41618345Medicaid