Provider Demographics
NPI:1417201336
Name:DEKORTE, JAMIE LAUREN (RN, BSN)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LAUREN
Last Name:DEKORTE
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 E BELTLINE AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4336
Mailing Address - Country:US
Mailing Address - Phone:616-464-0279
Mailing Address - Fax:616-301-1971
Practice Address - Street 1:1490 E BELTLINE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4336
Practice Address - Country:US
Practice Address - Phone:616-464-0279
Practice Address - Fax:616-301-1971
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704222608163WR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0400XNursing Service ProvidersRegistered NurseRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704222608OtherNURSING LICENSE