Provider Demographics
NPI:1023167434
Name:DECAPUA, JEROME MICHAEL (DC)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:MICHAEL
Last Name:DECAPUA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 540
Mailing Address - Street 2:
Mailing Address - City:WILLOW CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:95573-0540
Mailing Address - Country:US
Mailing Address - Phone:530-629-2474
Mailing Address - Fax:
Practice Address - Street 1:39032 HIGHWAY 299
Practice Address - Street 2:SUITE 4
Practice Address - City:WILLOW CREEK
Practice Address - State:CA
Practice Address - Zip Code:95573-0540
Practice Address - Country:US
Practice Address - Phone:530-629-2474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15178111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0151780Medicare ID - Type Unspecified