Provider Demographics
NPI:1306961768
Name:DEITZ, JONATHAN W (DC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:W
Last Name:DEITZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4325 13TH AVE S
Mailing Address - Street 2:SUITE 5
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3341
Mailing Address - Country:US
Mailing Address - Phone:701-212-1419
Mailing Address - Fax:
Practice Address - Street 1:4325 13TH AVE S
Practice Address - Street 2:SUITE 5
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3341
Practice Address - Country:US
Practice Address - Phone:701-212-1419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND682111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19091OtherBCBS OF ND PROVIDER #
ND11334Medicaid
NDU76870Medicare UPIN
ND711368Medicare ID - Type Unspecified