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: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FORT JESSE RD STE 110
NORMAL IL
61761-6286
US

IV. Provider business mailing address

2200 FORT JESSE RD STE 110
NORMAL IL
61761-6286
US

V. Phone/Fax

Practice location:
  • Phone: 309-661-6290
  • Fax: 309-451-1354
Mailing address:
  • Phone: 309-661-6290
  • Fax: 309-451-1354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209021931
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209021931
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: