Provider Demographics
NPI:1790217651
Name:DIETZE, JARED
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:DIETZE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 N DENVER AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-5122
Mailing Address - Country:US
Mailing Address - Phone:402-834-2450
Mailing Address - Fax:402-834-2449
Practice Address - Street 1:618 N DENVER AVE
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-5122
Practice Address - Country:US
Practice Address - Phone:402-834-2450
Practice Address - Fax:402-834-2449
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NE34720208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE34720OtherMEDICAL LICENSE