Provider Demographics
NPI:1770667446
Name:TIEDEMAN, JANE ANN (OT)
Entity Type:Individual
Prefix:MRS
First Name:JANE
Middle Name:ANN
Last Name:TIEDEMAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27313 DOMINICA LN
Mailing Address - Street 2:
Mailing Address - City:RAMROD KEY
Mailing Address - State:FL
Mailing Address - Zip Code:33042-5453
Mailing Address - Country:US
Mailing Address - Phone:305-923-3820
Mailing Address - Fax:
Practice Address - Street 1:27313 DOMINICA LN
Practice Address - Street 2:
Practice Address - City:RAMROD KEY
Practice Address - State:FL
Practice Address - Zip Code:33042-5453
Practice Address - Country:US
Practice Address - Phone:305-923-3820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 10529225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL887682700Medicaid
FLZ019EAMedicare ID - Type Unspecified