Provider Demographics
NPI:1720321623
Name:DEESLIE, JONATHAN JOSEPH (HIS)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:JOSEPH
Last Name:DEESLIE
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 JACKSON ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-4778
Mailing Address - Country:US
Mailing Address - Phone:920-966-2700
Mailing Address - Fax:920-966-6060
Practice Address - Street 1:136 JACKSON ST
Practice Address - Street 2:SUITE 5
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-4778
Practice Address - Country:US
Practice Address - Phone:920-966-2700
Practice Address - Fax:920-966-6060
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1319-060237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist