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General NPI Number Information
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NPI Number | 1760054373
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Entity Type | Individual
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Provider Name | JACKSON RAY DIEDE MAT, ATC
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Gender | Male
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Dates
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Enumeration Date | 07/13/2021
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Last Update Date | 07/13/2021
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Provider Practice Location Address
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Address Line | 810 E 23RD ST
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City | SIOUX FALLS
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State | SD
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Zip | 57105-2135
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Country | US
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Telephone | 605-331-5890
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Fax |
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Provider Business Mailing Address
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Address Line | 117 S HIGH ST
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City | MENNO
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State | SD
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Zip | 57045-2170
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Country | US
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Telephone | 605-760-1566
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081S0010X
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Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 0714
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License Number State | SD
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