Provider Demographics
NPI:1578664561
Name:DEKKER, JOHN RAYMOND (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RAYMOND
Last Name:DEKKER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:586 LATHAM DR
Mailing Address - Street 2:SUITE 7
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914
Mailing Address - Country:US
Mailing Address - Phone:815-932-7926
Mailing Address - Fax:815-932-1269
Practice Address - Street 1:586 LATHAM DR
Practice Address - Street 2:SUITE 7
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914
Practice Address - Country:US
Practice Address - Phone:815-932-7926
Practice Address - Fax:815-932-1269
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0380041970111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL00667720Medicare ID - Type Unspecified
T37633Medicare UPIN