Healthcare Provider Details

I. General information

NPI: 1831416395
Provider Name (Legal Business Name): JAY ALAN DEDEKER MSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 04/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6711 MOUNTAIN VIEW RD STE 115
OOLTEWAH TN
37363-6667
US

IV. Provider business mailing address

6711 MOUNTAIN VIEW RD STE 115
OOLTEWAH TN
37363-6667
US

V. Phone/Fax

Practice location:
  • Phone: 423-238-1127
  • Fax: 423-238-1277
Mailing address:
  • Phone: 423-238-1127
  • Fax: 423-238-1277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: