Provider Demographics
NPI:1295883478
Name:DEJONG, GREGORY JAMES (LAT)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:JAMES
Last Name:DEJONG
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W1910 SLEEPY HOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:KAUKAUNA
Mailing Address - State:WI
Mailing Address - Zip Code:54130-9429
Mailing Address - Country:US
Mailing Address - Phone:920-788-4760
Mailing Address - Fax:
Practice Address - Street 1:W1910 SLEEPY HOLLOW CT
Practice Address - Street 2:
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130-9429
Practice Address - Country:US
Practice Address - Phone:920-788-4760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI74-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer