Provider Demographics
NPI:1265173678
Name:DIERKS, GREGOR JACKSON
Entity type:Individual
Prefix:
First Name:GREGOR
Middle Name:JACKSON
Last Name:DIERKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6051 ROMA DR APT 609
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4671
Mailing Address - Country:US
Mailing Address - Phone:971-563-3919
Mailing Address - Fax:
Practice Address - Street 1:6051 ROMA DR APT 609
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4671
Practice Address - Country:US
Practice Address - Phone:971-563-3919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program