Provider Demographics
NPI:1598156598
Name:DIERINGER, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:DIERINGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 TIMBLIN DR APT 7
Mailing Address - Street 2:
Mailing Address - City:KEWASKUM
Mailing Address - State:WI
Mailing Address - Zip Code:53040-9174
Mailing Address - Country:US
Mailing Address - Phone:920-980-4870
Mailing Address - Fax:
Practice Address - Street 1:402 1ST ST
Practice Address - Street 2:
Practice Address - City:RANDOM LAKE
Practice Address - State:WI
Practice Address - Zip Code:53075-1772
Practice Address - Country:US
Practice Address - Phone:920-994-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-11
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5612-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist