Provider Demographics
NPI:1649897034
Name:DIEDERICH, JENNIFER CHRISTINE (BCABA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CHRISTINE
Last Name:DIEDERICH
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5868 BAKER RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-5903
Mailing Address - Country:US
Mailing Address - Phone:612-245-5933
Mailing Address - Fax:
Practice Address - Street 1:5868 BAKER RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-5903
Practice Address - Country:US
Practice Address - Phone:612-245-5933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
01-16-7528103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst