Provider Demographics
NPI:1851721591
Name:DIERS, JO
Entity Type:Individual
Prefix:
First Name:JO
Middle Name:
Last Name:DIERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6425 NICOLLET AVE
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1675
Mailing Address - Country:US
Mailing Address - Phone:612-861-1675
Mailing Address - Fax:612-861-3446
Practice Address - Street 1:6425 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-1675
Practice Address - Country:US
Practice Address - Phone:612-861-1675
Practice Address - Fax:612-861-3446
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-15
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11476101YM0800X
MN2032101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health