Provider Demographics
NPI:1548605769
Name:DIETERT, JESSICA BEARDEN (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:BEARDEN
Last Name:DIETERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:NICOLE
Other - Last Name:BEARDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4419 FRONTIER TRL STE 110
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1567
Mailing Address - Country:US
Mailing Address - Phone:512-444-7208
Mailing Address - Fax:512-444-2343
Practice Address - Street 1:14008 SHADOWGLEN BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MANOR
Practice Address - State:TX
Practice Address - Zip Code:78653-3406
Practice Address - Country:US
Practice Address - Phone:512-444-7208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR7710207N00000X, 207ND0101X
TX1548605769207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine