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General NPI Number Information
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NPI Number | 1184134132
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Entity Type | Organization
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Legal Business Name | JACK L DEETJEN MD PLLC
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Dates
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Enumeration Date | 10/04/2017
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Last Update Date | 10/04/2017
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Provider Practice Location Address
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Address Line | 515 N KING ST STE 106
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City | SEGUIN
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State | TX
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Zip | 78155-4815
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Country | US
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Telephone | 830-379-8371
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Fax |
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Provider Business Mailing Address
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Address Line | 515 N KING ST STE 106
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City | SEGUIN
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State | TX
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Zip | 78155-4815
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Country | US
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Telephone | 830-379-8371
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | NORMA ENGELMANN
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Credential |
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Telephone | 830-379-8371
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | G4967
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License Number State | TX
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