Healthcare Provider Details

I. General information

NPI: 1659841898
Provider Name (Legal Business Name): KIMBERLY DIETRICH PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2018
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6700 BROWNS LAKE RD
JACKSON MI
49201-8379
US

IV. Provider business mailing address

15500 19 MILE RD STE 330
CLINTON TWP MI
48038-6313
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-8910
  • Fax: 517-787-1932
Mailing address:
  • Phone: 586-412-0016
  • Fax: 586-412-0117

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: