Provider Demographics
NPI:1225603327
Name:DEDECKER, JEROME JOSEPH
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:JOSEPH
Last Name:DEDECKER
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 1:26827 FORTROCK RD
Mailing Address - Street 2:
Mailing Address - City:SELIGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86337
Mailing Address - Country:US
Mailing Address - Phone:928-583-4245
Mailing Address - Fax:
Practice Address - Street 1:26827 FORTROCK RD
Practice Address - Street 2:
Practice Address - City:SELIGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86337
Practice Address - Country:US
Practice Address - Phone:928-583-4245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZB12876871163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZB12876871Medicaid