Healthcare Provider Details

I. General information

NPI: 1902914674
Provider Name (Legal Business Name): JENNIFER DIETER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MURABELLA PKWY STE 6
ST AUGUSTINE FL
32092-4540
US

IV. Provider business mailing address

PO BOX 117345
ATLANTA GA
30368-7345
US

V. Phone/Fax

Practice location:
  • Phone: 904-224-2666
  • Fax: 904-224-2667
Mailing address:
  • Phone: 904-346-3465
  • Fax: 904-858-6489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: