Healthcare Provider Details

I. General information

NPI: 1538139076
Provider Name (Legal Business Name): DEBORAH MARIE JERRELLS DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEBORAH MARIE MICKELSON D.M.D.

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 VALPARAISO PKWY
VALPARAISO FL
32580-1203
US

IV. Provider business mailing address

395 VALPARAISO PKWY
VALPARAISO FL
32580-1203
US

V. Phone/Fax

Practice location:
  • Phone: 850-678-2012
  • Fax: 715-344-7912
Mailing address:
  • Phone: 850-678-2012
  • Fax: 715-344-7912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN17382
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN17382
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: