Provider Demographics
NPI:1992251763
Name:DEHN, JACKSON
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:DEHN
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 1:26900 PURDUM RD
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:MD
Mailing Address - Zip Code:20872-1432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3RD MARINE LOGISTICS GROUP
Practice Address - Street 2:UNIT 38404
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96604-8404
Practice Address - Country:US
Practice Address - Phone:240-678-5940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman