Provider Demographics
NPI:1508919184
Name:DIETRICHSON, JEFF (PT)
Entity Type:Individual
Prefix:MR
First Name:JEFF
Middle Name:
Last Name:DIETRICHSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5670 GREENWOOD PLAZA BLVD STE LL110
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-2448
Mailing Address - Country:US
Mailing Address - Phone:303-694-9193
Mailing Address - Fax:303-779-0566
Practice Address - Street 1:5670 GREENWOOD PLAZA BLVD STE LL110
Practice Address - Street 2:
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-2448
Practice Address - Country:US
Practice Address - Phone:303-694-9193
Practice Address - Fax:303-779-0566
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2480225100000X
COPTL0016101225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI583444Medicaid
HIH101182Medicare PIN