Healthcare Provider Details

I. General information

NPI: 1649634189
Provider Name (Legal Business Name): JESSICA JACKSON DIETTER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 CAMELOT DR STE 200
VIRGINIA BEACH VA
23454-2440
US

IV. Provider business mailing address

1800 CAMELOT DR STE 200
VIRGINIA BEACH VA
23454-2440
US

V. Phone/Fax

Practice location:
  • Phone: 757-252-9600
  • Fax: 757-351-2905
Mailing address:
  • Phone: 757-252-9600
  • Fax: 757-351-2905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0102205711
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: