Provider Demographics
NPI:1043083728
Name:DIETZ, JEREMIAH LYNN
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:LYNN
Last Name:DIETZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-1233
Mailing Address - Country:US
Mailing Address - Phone:989-884-4206
Mailing Address - Fax:
Practice Address - Street 1:211 PRINCETON AVE
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-1233
Practice Address - Country:US
Practice Address - Phone:989-884-4206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst