Provider Demographics
NPI:1639493471
Name:DIETZEL, BETH ANN-JAMISON (PHD)
Entity Type:Individual
Prefix:DR
First Name:BETH
Middle Name:ANN-JAMISON
Last Name:DIETZEL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:BETH
Other - Middle Name:ANN
Other - Last Name:JAMISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:1822 THRUSHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-5760
Mailing Address - Country:US
Mailing Address - Phone:269-327-4388
Mailing Address - Fax:
Practice Address - Street 1:5500 ARMSTRONG RD
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49037-7314
Practice Address - Country:US
Practice Address - Phone:269-966-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014389103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical