Basic Information
| Provider Information | |||||||||
| NPI: | 1902914674 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | DIETER | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 117345 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303687345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043463465 | ||||||||
| FaxNumber: | 9048586489 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 MURABELLA PKWY STE 6 | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320924540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042242666 | ||||||||
| FaxNumber: | 9042242667 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 18123 | 01 | FL | LICENSE # | OTHER |