Healthcare Provider Details

I. General information

NPI: 1326910993
Provider Name (Legal Business Name): JEREMIAH RUSSELL DECKARD JR. ASW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2025
Last Update Date: 05/03/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4344 LATHAM ST STE 119
RIVERSIDE CA
92501-0400
US

IV. Provider business mailing address

4344 LATHAM ST STE 119
RIVERSIDE CA
92501-0400
US

V. Phone/Fax

Practice location:
  • Phone: 840-888-5310
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW132837
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: