Provider Demographics
NPI:1285890988
Name:DIEPOLD, JEFFREY JOHN (PT)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JOHN
Last Name:DIEPOLD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 BOULDERS PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4067
Mailing Address - Country:US
Mailing Address - Phone:804-560-5595
Mailing Address - Fax:804-560-9029
Practice Address - Street 1:8266 ATLEE RD
Practice Address - Street 2:SUITE 133PT
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-1804
Practice Address - Country:US
Practice Address - Phone:804-569-1665
Practice Address - Fax:804-569-1628
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305205531225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1285890988Medicaid
VAP00630296OtherRAILROAD MEDICARE
VAP00630296OtherRAILROAD MEDICARE
VA0472640012Medicare NSC