Provider Demographics
NPI:1053499962
Name:DEBEQUE SCHOOL DISTRICT 49JT
Entity Type:Organization
Organization Name:DEBEQUE SCHOOL DISTRICT 49JT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAID COORDINATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:D
Authorized Official - Last Name:WICKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-254-5302
Mailing Address - Street 1:730 MINTER AVE
Mailing Address - Street 2:
Mailing Address - City:DEBEQUE
Mailing Address - State:CO
Mailing Address - Zip Code:81630
Mailing Address - Country:US
Mailing Address - Phone:970-283-5596
Mailing Address - Fax:970-283-5598
Practice Address - Street 1:730 MINTER AVE
Practice Address - Street 2:
Practice Address - City:DEBEQUE
Practice Address - State:CO
Practice Address - Zip Code:81630
Practice Address - Country:US
Practice Address - Phone:970-283-5596
Practice Address - Fax:970-283-5598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
COUN20529821Medicaid