Provider Demographics
NPI:1376007179
Name:DIETZ, JENNIFER (LMT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DIETZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 TUTHILLTOWN RD
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:NY
Mailing Address - Zip Code:12525-5514
Mailing Address - Country:US
Mailing Address - Phone:845-590-1298
Mailing Address - Fax:
Practice Address - Street 1:2356 ROUTE 44 55 STE F
Practice Address - Street 2:
Practice Address - City:GARDINER
Practice Address - State:NY
Practice Address - Zip Code:12525-5335
Practice Address - Country:US
Practice Address - Phone:845-590-1298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030324-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist