Healthcare Provider Details

I. General information

NPI: 1487898870
Provider Name (Legal Business Name): JENNIFER ANN DIERS LPN, MHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2009
Last Update Date: 04/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 E VINE ST
VIENNA IL
62995-1612
US

IV. Provider business mailing address

151 PYRAMID LN
CREAL SPRINGS IL
62922-3852
US

V. Phone/Fax

Practice location:
  • Phone: 618-658-2611
  • Fax: 618-658-2501
Mailing address:
  • Phone: 217-725-4823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number043024214
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: