=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538139076
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEBORAH MARIE JERRELLS DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2006
-----------------------------------------------------
Last Update Date | 07/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 395 VALPARAISO PKWY
-----------------------------------------------------
City | VALPARAISO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32580-1203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-678-2012
-----------------------------------------------------
Fax | 715-344-7912
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 395 VALPARAISO PKWY
-----------------------------------------------------
City | VALPARAISO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32580-1203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-678-2012
-----------------------------------------------------
Fax | 715-344-7912
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN17382
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN17382
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------