1790953289 NPI number — JACK L DEETJEN MD

Table of content: (NPI 1790953289)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790953289 NPI number — JACK L DEETJEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACK L DEETJEN MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790953289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
515 N KING ST
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
SEGUIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78155-4801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-379-8371
Provider Business Mailing Address Fax Number:
830-379-8378

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 N KING
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
SEGUIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78155-4815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-379-8371
Provider Business Practice Location Address Fax Number:
830-379-8378
Provider Enumeration Date:
02/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ENGELMANN
Authorized Official First Name:
NORMA
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
830-379-8371

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  G4967 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 033725501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1699723320 . This is a "N P I" identifier . This identifiers is of the category "OTHER".




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