Provider Demographics
NPI:1790953289
Name:JACK L DEETJEN MD
Entity Type:Organization
Organization Name:JACK L DEETJEN MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:ENGELMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-379-8371
Mailing Address - Street 1:515 N KING ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-4801
Mailing Address - Country:US
Mailing Address - Phone:830-379-8371
Mailing Address - Fax:830-379-8378
Practice Address - Street 1:515 N KING
Practice Address - Street 2:SUITE 106
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-4815
Practice Address - Country:US
Practice Address - Phone:830-379-8371
Practice Address - Fax:830-379-8378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4967332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX033725501Medicaid
1699723320OtherN P I
TX0471550001Medicare NSC
1699723320OtherN P I
TX033725501Medicaid