Provider Demographics
NPI:1225857857
Name:DETTINGER, JADE ISIS (NA)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:ISIS
Last Name:DETTINGER
Suffix:
Gender:F
Credentials:NA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 CHESTNUT ST APT 1204
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17101-2791
Mailing Address - Country:US
Mailing Address - Phone:570-594-2511
Mailing Address - Fax:
Practice Address - Street 1:301 CHESTNUT ST APT 1204
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17101-2791
Practice Address - Country:US
Practice Address - Phone:570-594-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide