Provider Demographics
NPI:1588301634
Name:DIETCH, JESSICA (PHD, DBSM)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:DIETCH
Suffix:
Gender:F
Credentials:PHD, DBSM
Other - Prefix:DR
Other - First Name:JESSEE
Other - Middle Name:
Other - Last Name:DIETCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD, DBSM
Mailing Address - Street 1:3481 NW MAXINE CIR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3481 NW MAXINE CIR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3727
Practice Address - Country:US
Practice Address - Phone:541-900-5941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3295103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical