Provider Demographics
NPI:1346254141
Name:DEITCHMAN, JACK KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:KENNETH
Last Name:DEITCHMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:140 LITTON DRIVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945
Mailing Address - Country:US
Mailing Address - Phone:530-274-8483
Mailing Address - Fax:530-271-2067
Practice Address - Street 1:140 LITTON DRIVE
Practice Address - Street 2:SUITE 110
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945
Practice Address - Country:US
Practice Address - Phone:530-274-8483
Practice Address - Fax:530-271-2067
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2009-03-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG262972083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine