Healthcare Provider Details

I. General information

NPI: 1427629187
Provider Name (Legal Business Name): JACOB DIETZ DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2021
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7710 OLENTANGY RIVER RD STE 100
COLUMBUS OH
43235-1353
US

IV. Provider business mailing address

1378 VIRGINIA AVE
COLUMBUS OH
43212-3039
US

V. Phone/Fax

Practice location:
  • Phone: 614-841-3900
  • Fax:
Mailing address:
  • Phone: 859-547-9555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT019403
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: