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General NPI Number Information
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NPI Number | 1982100699
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Entity Type | Individual
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Provider Name | JAY ALAN DETERMAN
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Gender | Male
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Dates
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Enumeration Date | 04/02/2018
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Last Update Date | 03/25/2024
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Provider Practice Location Address
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Address Line | 855 12TH ST NW APT 206
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City | VALLEY CITY
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State | ND
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Zip | 58072-2042
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Country | US
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Telephone | 605-830-0603
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Fax |
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Provider Business Mailing Address
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Address Line | 701 15TH ST SE APT 311
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City | ORANGE CITY
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State | IA
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Zip | 51041-1877
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Country | US
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Telephone | 605-830-0603
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 0700
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License Number State | SD
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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