Provider Demographics
NPI:1750786406
Name:DIEDERICH, JONNIE (PTA)
Entity type:Individual
Prefix:
First Name:JONNIE
Middle Name:
Last Name:DIEDERICH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 SUMMIT RIDGE DR
Mailing Address - Street 2:#5321
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-9014
Mailing Address - Country:US
Mailing Address - Phone:775-827-3777
Mailing Address - Fax:775-827-1013
Practice Address - Street 1:1575 ROBB DR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523-3746
Practice Address - Country:US
Practice Address - Phone:775-827-3777
Practice Address - Fax:775-827-1013
Is Sole Proprietor?:No
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVA-0728225200000X
WI1954-19225200000X
CO0013299225200000X
OR09039225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant