Provider Demographics
NPI:1316214554
Name:DIETZ, JILLIAN VICTORIA (APN -CNP)
Entity Type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:VICTORIA
Last Name:DIETZ
Suffix:
Gender:F
Credentials:APN -CNP
Other - Prefix:MISS
Other - First Name:JILLIAN
Other - Middle Name:VICTORIA
Other - Last Name:LESSARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 3063
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-0063
Mailing Address - Country:US
Mailing Address - Phone:219-513-8923
Mailing Address - Fax:219-513-8941
Practice Address - Street 1:9008 INDIANAPOLIS BLVD
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-2501
Practice Address - Country:US
Practice Address - Phone:219-513-8923
Practice Address - Fax:219-513-8941
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.009223363LF0000X
IN209009223363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300000084Medicaid