Provider Demographics
NPI:1538139076
Name:JERRELLS, DEBORAH MARIE (DMD)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:MARIE
Last Name:JERRELLS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MRS
Other - First Name:DEBORAH
Other - Middle Name:MARIE
Other - Last Name:MICKELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:395 VALPARAISO PKWY
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:FL
Mailing Address - Zip Code:32580-1203
Mailing Address - Country:US
Mailing Address - Phone:850-678-2012
Mailing Address - Fax:715-344-7912
Practice Address - Street 1:395 VALPARAISO PKWY
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:FL
Practice Address - Zip Code:32580-1203
Practice Address - Country:US
Practice Address - Phone:850-678-2012
Practice Address - Fax:715-344-7912
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17382122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice