Basic Information
Provider Information | |||||||||
NPI: | 1194192062 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEKKER | ||||||||
FirstName: | JAMI | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CYNECKI | ||||||||
OtherFirstName: | JAMI | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1678 STONY CREEK DR | ||||||||
Address2: |   | ||||||||
City: | ROCHESTER | ||||||||
State: | MI | ||||||||
PostalCode: | 483071783 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9896001487 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11800 E 12 MILE RD | ||||||||
Address2: |   | ||||||||
City: | WARREN | ||||||||
State: | MI | ||||||||
PostalCode: | 480933472 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5865761615 | ||||||||
FaxNumber: | 5865761628 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/27/2015 | ||||||||
LastUpdateDate: | 10/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9109793 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X |   | MI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.