Provider Demographics
NPI:1659659282
Name:DER, JAYDEN (MD)
Entity Type:Individual
Prefix:
First Name:JAYDEN
Middle Name:
Last Name:DER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 NEENAH CTR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3070
Mailing Address - Country:US
Mailing Address - Phone:920-831-5050
Mailing Address - Fax:920-738-6507
Practice Address - Street 1:2400 E CAPITOL DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8728
Practice Address - Country:US
Practice Address - Phone:920-831-5050
Practice Address - Fax:920-738-6507
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301098870208100000X
WI65587208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1659659282Medicaid