MEDICARE: MRS. JILL A DEDERA L.AC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	0706	AZ

General Provider Information

NPI Number	:	1548696255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JILL A DEDERA L.AC.

Provider Business Mailing Address
First Line	:	3331 S MOORE CIR
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86005-8501
Country	:	US
Telephone Number	:	928-699-6494
Fax Number	:

Provider Business Practice Location Address
First Line	:	3331 S MOORE CIR
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86005-8501
Country	:	US
Telephone Number	:	928-699-6494
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2013
Last Update Date	:	09/25/2013

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