Individual
JEROME JOSEPH DEDECKER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
26827 FORTROCK RD, SELIGMAN, AZ 86337
(928) 583-4245
Mailing address
26827 FORTROCK RD, SELIGMAN, AZ 86337
(928) 583-4245
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
Primary
B12876871
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
B12876871
—
AZ
Enumeration date
05/21/2021
Last updated
05/21/2021
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