Provider Demographics
NPI:1760271241
Name:RIDENOUR-DIETZE, JENNIFER CHARLENE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CHARLENE
Last Name:RIDENOUR-DIETZE
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 1:8101 DIAMOND HEIGHTS ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89143-5129
Mailing Address - Country:US
Mailing Address - Phone:682-472-0153
Mailing Address - Fax:
Practice Address - Street 1:8101 DIAMOND HEIGHTS ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89143-5129
Practice Address - Country:US
Practice Address - Phone:682-472-0153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-02
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNVMT.3827225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist