Provider Demographics
NPI:1982100699
Name:DETERMAN, JAY ALAN
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:ALAN
Last Name:DETERMAN
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 1:701 15TH ST SE APT 311
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51041-1877
Mailing Address - Country:US
Mailing Address - Phone:605-830-0603
Mailing Address - Fax:
Practice Address - Street 1:855 12TH ST NW APT 206
Practice Address - Street 2:
Practice Address - City:VALLEY CITY
Practice Address - State:ND
Practice Address - Zip Code:58072-2042
Practice Address - Country:US
Practice Address - Phone:605-830-0603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD07002255A2300X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0700OtherCERTIFIED ATHLETIC TRAINER