Provider Demographics
NPI:1760054373
Name:DIEDE, JACKSON RAY (MAT, ATC)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:RAY
Last Name:DIEDE
Suffix:
Gender:M
Credentials:MAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 S HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MENNO
Mailing Address - State:SD
Mailing Address - Zip Code:57045-2170
Mailing Address - Country:US
Mailing Address - Phone:605-760-1566
Mailing Address - Fax:
Practice Address - Street 1:810 E 23RD ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-2135
Practice Address - Country:US
Practice Address - Phone:605-331-5890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD07142081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDWSLW01080864OtherBLUECROSS BLUESHIELD