Provider Demographics
NPI:1154551885
Name:DJAM, JEROME CHIA
Entity type:Individual
Prefix:MR
First Name:JEROME
Middle Name:CHIA
Last Name:DJAM
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 1:11600 INTERLACHEN RD
Mailing Address - Street 2:
Mailing Address - City:CHISAGO CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55013-7311
Mailing Address - Country:US
Mailing Address - Phone:651-558-1454
Mailing Address - Fax:
Practice Address - Street 1:11600 INTERLACHEN RD
Practice Address - Street 2:
Practice Address - City:CHISAGO CITY
Practice Address - State:MN
Practice Address - Zip Code:55013-7311
Practice Address - Country:US
Practice Address - Phone:651-558-1454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-15
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1050106-2-AFC171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator