Provider Demographics
NPI:1639447162
Name:DIETIKER, JILL MAUREEN (PHN)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:MAUREEN
Last Name:DIETIKER
Suffix:
Gender:F
Credentials:PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20111 CEDAR RD N
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5939
Mailing Address - Country:US
Mailing Address - Phone:209-533-7415
Mailing Address - Fax:
Practice Address - Street 1:20111 CEDAR RD N
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5939
Practice Address - Country:US
Practice Address - Phone:209-533-7415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN358410163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health