Provider Demographics
NPI:1508636366
Name:DECASTEELE, JEREMIAH JORDAN
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:JORDAN
Last Name:DECASTEELE
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 1:63 OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-6106
Mailing Address - Country:US
Mailing Address - Phone:631-992-0705
Mailing Address - Fax:
Practice Address - Street 1:63 OHIO AVE
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6106
Practice Address - Country:US
Practice Address - Phone:631-992-0705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman