Provider Demographics
NPI:1225586548
Name:DIEHL, JODIE (REVEREND)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:DIEHL
Suffix:
Gender:F
Credentials:REVEREND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481 S BASS LAKE DR
Mailing Address - Street 2:
Mailing Address - City:VESTABURG
Mailing Address - State:MI
Mailing Address - Zip Code:48891-9428
Mailing Address - Country:US
Mailing Address - Phone:989-330-6975
Mailing Address - Fax:
Practice Address - Street 1:481 S BASS LAKE DR
Practice Address - Street 2:
Practice Address - City:VESTABURG
Practice Address - State:MI
Practice Address - Zip Code:48891-9428
Practice Address - Country:US
Practice Address - Phone:989-330-6975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker