Healthcare Provider Details

I. General information

NPI: 1225629447
Provider Name (Legal Business Name): JAY MARTIN DIETRICH APN, NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2021
Last Update Date: 01/30/2021
Certification Date: 01/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E WASHINGTON ST
BLOOMINGTON IL
61701-4364
US

IV. Provider business mailing address

206 BEACON CIR
BLOOMINGTON IL
61704-1414
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-3311
  • Fax:
Mailing address:
  • Phone: 309-502-0379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209021931
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041446858
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: