Provider Demographics
NPI:1790440667
Name:DEDECKER - JAMIESON, KIMBERLY S (NBC-HWC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:S
Last Name:DEDECKER - JAMIESON
Suffix:
Gender:F
Credentials:NBC-HWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1649 ROYAL OAKS CT
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-4049
Mailing Address - Country:US
Mailing Address - Phone:817-995-6435
Mailing Address - Fax:
Practice Address - Street 1:1649 ROYAL OAKS CT
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-4049
Practice Address - Country:US
Practice Address - Phone:817-995-6435
Practice Address - Fax:817-912-1310
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-04
Last Update Date:2024-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXA-3279539171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach