Healthcare Provider Details

I. General information

NPI: 1912824061
Provider Name (Legal Business Name): JACOB RUBEN DEHECK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 W LAKE ST STE 200
MINNEAPOLIS MN
55408-3565
US

IV. Provider business mailing address

1221 W LAKE ST STE 200
MINNEAPOLIS MN
55408-3565
US

V. Phone/Fax

Practice location:
  • Phone: 612-824-1036
  • Fax: 612-824-7862
Mailing address:
  • Phone: 612-824-1036
  • Fax: 612-824-7862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number127347
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: