Provider Demographics
NPI:1861427510
Name:DIEBOLD, JENNIFER ANN (AUD)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ANN
Last Name:DIEBOLD
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 RICHARDSON RD
Mailing Address - Street 2:APT. 111
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-6018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1390 US HIGHWAY 61
Practice Address - Street 2:SUITE 3100
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4137
Practice Address - Country:US
Practice Address - Phone:636-931-7380
Practice Address - Fax:636-937-5546
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116740231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1316065972OtherGROUP NPI
MO1316065972OtherGROUP NPI