Provider Demographics
NPI:1396149217
Name:DEEKEN, SPENSER
Entity type:Individual
Prefix:
First Name:SPENSER
Middle Name:
Last Name:DEEKEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1177 HAMPTON LN
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA
Mailing Address - State:MO
Mailing Address - Zip Code:65018-9131
Mailing Address - Country:US
Mailing Address - Phone:573-694-5156
Mailing Address - Fax:
Practice Address - Street 1:3308 W EDGEWOOD DR STE F
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6891
Practice Address - Country:US
Practice Address - Phone:573-638-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160125102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer