Provider Demographics
NPI:1720857717
Name:DIETZ, JENNIFER (LDO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DIETZ
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:COX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14505 NE FOURTH PLAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-5003
Mailing Address - Country:US
Mailing Address - Phone:360-258-2651
Mailing Address - Fax:360-896-7308
Practice Address - Street 1:14505 NE FOURTH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-5003
Practice Address - Country:US
Practice Address - Phone:360-258-2651
Practice Address - Fax:360-896-7308
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-01
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO60887277156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty