Provider Demographics
NPI:1225629447
Name:DIETRICH, JAY MARTIN (APN, NP-C)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:MARTIN
Last Name:DIETRICH
Suffix:
Gender:M
Credentials:APN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 BEACON CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-1414
Mailing Address - Country:US
Mailing Address - Phone:309-502-0379
Mailing Address - Fax:
Practice Address - Street 1:2200 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4364
Practice Address - Country:US
Practice Address - Phone:309-662-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-30
Last Update Date:2021-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021931363L00000X
IL041446858163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse