Provider Demographics
NPI:1053401216
Name:DIETRICH, JENNIFER E (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:E
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:MD
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 4775
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4775
Mailing Address - Country:US
Mailing Address - Phone:713-798-1850
Mailing Address - Fax:713-798-1702
Practice Address - Street 1:6620 MAIN ST
Practice Address - Street 2:SUITE 1450
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2348
Practice Address - Country:US
Practice Address - Phone:713-798-7500
Practice Address - Fax:713-798-6956
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL63582080A0000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX187205302Medicaid
TX8J4825Medicare PIN
I08785Medicare UPIN
TX187205302Medicaid
TX8J4826Medicare PIN
TX8L2198Medicare PIN