Provider Demographics
NPI:1477855575
Name:DIETER, JENNIFER RENEE (BS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEE
Last Name:DIETER
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-2760
Mailing Address - Country:US
Mailing Address - Phone:918-619-2343
Mailing Address - Fax:
Practice Address - Street 1:101 SOUTH GIBSON
Practice Address - Street 2:
Practice Address - City:WEBBERS FALLS
Practice Address - State:OK
Practice Address - Zip Code:74470
Practice Address - Country:US
Practice Address - Phone:918-441-3468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174H00000XOther Service ProvidersHealth Educator
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist