Provider Demographics
NPI:1275511891
Name:DIETZ, JENNIFER (PT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:DIETZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:39 CINEMA BLVD
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-3290
Mailing Address - Country:US
Mailing Address - Phone:978-466-6677
Mailing Address - Fax:978-466-1133
Practice Address - Street 1:39 CINEMA BLVD
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-3290
Practice Address - Country:US
Practice Address - Phone:978-466-6677
Practice Address - Fax:978-466-1133
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15578225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY67903OtherBLUE CROSS
MA462286OtherTUFTS
MA462286OtherTUFTS