Provider Demographics
NPI:1699723320
Name:DEETJEN, JACK L (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:L
Last Name:DEETJEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 N KING ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-4815
Mailing Address - Country:US
Mailing Address - Phone:830-379-8371
Mailing Address - Fax:830-379-8378
Practice Address - Street 1:515 N KING ST
Practice Address - Street 2:SUITE 106
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-4815
Practice Address - Country:US
Practice Address - Phone:830-379-8371
Practice Address - Fax:830-379-8378
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TXG4967207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00H38YOtherBCBS
TX033725501Medicaid
F23659Medicare UPIN
TX0471550001Medicare NSC
TX033725501Medicaid