Provider Demographics
NPI:1205502580
Name:DIETRICH, JESSICA ROSE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:DIETRICH
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 1:2639 DONEGAL ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-1963
Mailing Address - Country:US
Mailing Address - Phone:217-370-5863
Mailing Address - Fax:866-244-8819
Practice Address - Street 1:2639 DONEGAL ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-1963
Practice Address - Country:US
Practice Address - Phone:217-370-5863
Practice Address - Fax:866-244-8819
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-18
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT89050133V00000X
WADI61023969133V00000X
ORLD-D10209815133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered