Provider Demographics
NPI:1285215657
Name:DIETHRICH, JENNIFER JO (LPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JO
Last Name:DIETHRICH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 SUNDANCE CIR
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-8853
Mailing Address - Country:US
Mailing Address - Phone:970-946-7002
Mailing Address - Fax:
Practice Address - Street 1:100 JENKINS RANCH RD
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-9474
Practice Address - Country:US
Practice Address - Phone:970-946-7002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-17
Last Update Date:2021-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0016973101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional