Provider Demographics
NPI:1326494055
Name:DILTZ, JERA
Entity Type:Individual
Prefix:
First Name:JERA
Middle Name:
Last Name:DILTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-3811
Mailing Address - Country:US
Mailing Address - Phone:580-379-4085
Mailing Address - Fax:580-379-4062
Practice Address - Street 1:111 N HUDSON ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-3811
Practice Address - Country:US
Practice Address - Phone:580-379-4085
Practice Address - Fax:580-379-4062
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health