Provider Demographics
NPI:1477833762
Name:DIETZEN, JAIME (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:JAIME
Middle Name:
Last Name:DIETZEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2458 SISKIYOU ST
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-6790
Mailing Address - Country:US
Mailing Address - Phone:972-743-4416
Mailing Address - Fax:
Practice Address - Street 1:2003 SE WALTON BLVD
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3725
Practice Address - Country:US
Practice Address - Phone:479-464-5925
Practice Address - Fax:479-464-4275
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX605771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical