Basic Information
| Provider Information | |||||||||
| NPI: | 1225629447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIETRICH | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | MARTIN | ||||||||
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| Credential: | APN, NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 BEACON CIR | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617041414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3095020379 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2200 E WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617014364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096623311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2021 | ||||||||
| LastUpdateDate: | 01/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209021931 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 163W00000X | 041446858 | IL | N | Nursing Service Providers | Registered Nurse |
No ID Information.