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General NPI Number Information
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NPI Number | 1497960983
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Entity Type | Organization
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Legal Business Name | JAN DEBLIECK MD PA
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Dates
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Enumeration Date | 05/10/2007
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Last Update Date | 07/17/2007
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Provider Practice Location Address
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Address Line | 13176 W PERSIMMON LN
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City | BOISE
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State | ID
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Zip | 83713-1986
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Country | US
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Telephone | 208-939-5030
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Fax | 208-939-1892
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Provider Business Mailing Address
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Address Line | 13176 W PERSIMMON LN
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City | BOISE
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State | ID
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Zip | 83713-1986
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Country | US
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Telephone | 208-939-5030
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Fax | 208-939-1892
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Authorized Official
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Title or Position | PHYSICIAN-OWNER
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Name | DR. JENNIFER DEBLIECK
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Credential | M.D.
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Telephone | 208-939-5030
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | M7045
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License Number State | ID
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