Provider Demographics
NPI:1437645959
Name:DECK, JONATHAN G
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:G
Last Name:DECK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 HALLOWAY LN
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-9290
Mailing Address - Country:US
Mailing Address - Phone:313-590-8188
Mailing Address - Fax:
Practice Address - Street 1:46961 VANDYKE AVE
Practice Address - Street 2:
Practice Address - City:SHEBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48317
Practice Address - Country:US
Practice Address - Phone:586-991-5205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008727363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant