Provider Demographics
NPI:1659350254
Name:TIETGEN, JEREMY JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:JOHN
Last Name:TIETGEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-6901
Mailing Address - Country:US
Mailing Address - Phone:605-336-1188
Mailing Address - Fax:605-336-2677
Practice Address - Street 1:412 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-6901
Practice Address - Country:US
Practice Address - Phone:605-336-1188
Practice Address - Fax:605-336-2677
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1020111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD41934Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL NUMBE
SD42359Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
SDU87990Medicare UPIN