Provider Demographics
NPI:1538139076
Name:JERRELLS, DEBORAH MARIE (DMD)
Entity Type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:MARIE
Last Name:JERRELLS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MRS
Other - First Name:DEBORAH
Other - Middle Name:MARIE
Other - Last Name:MICKELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:2512 RIO GRANDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MERRILL
Mailing Address - State:WI
Mailing Address - Zip Code:54452
Mailing Address - Country:US
Mailing Address - Phone:715-218-3111
Mailing Address - Fax:715-344-7912
Practice Address - Street 1:5514 US HIGHWAY 10 E
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54482
Practice Address - Country:US
Practice Address - Phone:715-344-7911
Practice Address - Fax:715-344-7912
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN173821223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice