Provider Demographics
NPI:1871698373
Name:DECKARD, JODI M (NP)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:M
Last Name:DECKARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:M
Other - Last Name:DENTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2003 BLAIR CT
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21015-1678
Mailing Address - Country:US
Mailing Address - Phone:410-776-3339
Mailing Address - Fax:
Practice Address - Street 1:333 WASHINGTON AVE N STE 5000
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55401-1331
Practice Address - Country:US
Practice Address - Phone:612-659-7111
Practice Address - Fax:612-659-7101
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR174883363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000374582OtherBCBS - MARY STREET
IN200802970Medicaid
KY78015609Medicaid
IN000000381104OtherBCBS - GATEWAY
IN534980YYMedicare ID - Type Unspecified
INP00260239Medicare ID - Type UnspecifiedRR MCARE #
KY78015609Medicaid
TN3341100Medicare PIN