Basic Information
| Provider Information | |||||||||
| NPI: | 1487692067 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEJECACION | ||||||||
| FirstName: | JODIE | ||||||||
| MiddleName: | PEDEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9255 DALLAS PKWY STE 110 | ||||||||
| Address2: | |||||||||
| City: | FRISCO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750334211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723771490 | ||||||||
| FaxNumber: | 9723771499 | ||||||||
| Practice Location | |||||||||
| Address1: | 9255 DALLAS PKWY STE 110 | ||||||||
| Address2: | |||||||||
| City: | FRISCO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750334211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723771490 | ||||||||
| FaxNumber: | 9723771499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 11/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M0053 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 176748501 | 05 | TX | MEDICAID | 176748502 | 01 | TX | MEDICAID OTHER | OTHER |