Provider Demographics
NPI:1053964452
Name:DIETZ, JENNY
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:DIETZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11809 241ST AVE
Mailing Address - Street 2:
Mailing Address - City:HARMONY
Mailing Address - State:MN
Mailing Address - Zip Code:55939-6515
Mailing Address - Country:US
Mailing Address - Phone:260-265-0799
Mailing Address - Fax:
Practice Address - Street 1:602 8TH ST SW
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:IA
Practice Address - Zip Code:50009-2301
Practice Address - Country:US
Practice Address - Phone:515-414-1830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-24
Last Update Date:2024-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG155693363LP0808X
AZ233383363LP0808X
FL11018672363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health