Provider Demographics
NPI:1700126224
Name:DIEBOLD, JODY SUSANNE (RD, LD)
Entity Type:Individual
Prefix:MS
First Name:JODY
Middle Name:SUSANNE
Last Name:DIEBOLD
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5044
Mailing Address - Country:US
Mailing Address - Phone:573-472-7619
Mailing Address - Fax:573-472-7149
Practice Address - Street 1:1008 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5044
Practice Address - Country:US
Practice Address - Phone:573-472-7619
Practice Address - Fax:573-472-7149
Is Sole Proprietor?:No
Enumeration Date:2013-02-20
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004003165133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered