Provider Demographics
NPI:1710566336
Name:DEDEAUX, JILLIAN R (CSFA)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:R
Last Name:DEDEAUX
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7095
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-7095
Mailing Address - Country:US
Mailing Address - Phone:228-297-6640
Mailing Address - Fax:
Practice Address - Street 1:14247 N SWAN RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-8551
Practice Address - Country:US
Practice Address - Phone:228-297-6640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical