Provider Demographics
NPI:1851368864
Name:DECKER, JENELL R (MD)
Entity Type:Individual
Prefix:
First Name:JENELL
Middle Name:R
Last Name:DECKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 N GRAND AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163
Mailing Address - Country:US
Mailing Address - Phone:509-808-1933
Mailing Address - Fax:
Practice Address - Street 1:1125 SE WASHINGTON
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99164-0001
Practice Address - Country:US
Practice Address - Phone:509-335-6127
Practice Address - Fax:509-335-6223
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60294725207Q00000X
VA0101243504207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64001423Medicaid
KY1274586Medicare PIN
VAMC10054Medicare PIN
H24917Medicare UPIN