Healthcare Provider Details

I. General information

NPI: 1790917979
Provider Name (Legal Business Name): JENNIFER DIETZ RD, CDE, LDN, MSPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 04/22/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 PINEY FOREST RD STE 306D
DANVILLE VA
24540-2869
US

IV. Provider business mailing address

625 PINEY FOREST RD STE 306D
DANVILLE VA
24540-2869
US

V. Phone/Fax

Practice location:
  • Phone: 434-548-0476
  • Fax: 434-791-3330
Mailing address:
  • Phone: 434-548-0476
  • Fax: 434-791-3330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL001930
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number862411
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: