Healthcare Provider Details

I. General information

NPI: 1427819721
Provider Name (Legal Business Name): DEREK JUSTICE JAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2024
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

03920 SOUTHLAND RD
NEW BREMEN OH
45869-9790
US

IV. Provider business mailing address

830 W MAIN ST
COLDWATER OH
45828-1626
US

V. Phone/Fax

Practice location:
  • Phone: 419-629-2772
  • Fax: 419-629-3613
Mailing address:
  • Phone: 567-890-7143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0036746
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: