Provider Demographics
NPI:1346950698
Name:DEJEAN, PHABIAN TREYVONNE
Entity type:Individual
Prefix:
First Name:PHABIAN
Middle Name:TREYVONNE
Last Name:DEJEAN
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 1:104 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:KAUKAUNA
Mailing Address - State:WI
Mailing Address - Zip Code:54130-2447
Mailing Address - Country:US
Mailing Address - Phone:920-809-1023
Mailing Address - Fax:
Practice Address - Street 1:104 W 4TH ST
Practice Address - Street 2:
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130-2447
Practice Address - Country:US
Practice Address - Phone:920-809-1023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI00192593104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness