Jonathan A Dereszynski

Key facts

NPI

1346758802

Entity type

Individual (NPI type 1)

Primary specialty

Behavior Technician 106S00000X

Practice address

1491 N Wagner Rd
Essexville, MI 48732

Phone

(623) 695-3464

NPI assigned

Jan 18, 2018

Sex

Male

Sole proprietor

Yes

Medicare participation

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD)

No

State licenses

Specialties & licenses

Addresses

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Oct 4, 2018.

{
    "created_epoch": "1516233600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1538611200000",
    "number": "1346758802",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1491 N WAGNER RD",
            "city": "ESSEXVILLE",
            "state": "MI",
            "postal_code": "487329698",
            "telephone_number": "623-695-3464"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1491 N WAGNER RD",
            "city": "ESSEXVILLE",
            "state": "MI",
            "postal_code": "48732",
            "telephone_number": "623-695-3464"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DERESZYNSKI",
        "first_name": "JONATHAN",
        "middle_name": "A",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2018-01-18",
        "last_updated": "2018-10-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225700000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Massage Therapist",
            "state": "MI",
            "license": "M998794",
            "primary": false
        },
        {
            "code": "106S00000X",
            "taxonomy_group": "",
            "desc": "Behavior Technician",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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