Provider Demographics
NPI:1275321200
Name:RIEDEMAN, JACKSON
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:RIEDEMAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9822 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-1002
Mailing Address - Country:US
Mailing Address - Phone:320-309-7399
Mailing Address - Fax:
Practice Address - Street 1:9822 N 1ST ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-1002
Practice Address - Country:US
Practice Address - Phone:320-309-7399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered