NPIMap

Individual provider Active NPI

Jaclyn Dietzold, M.D.

  • Psychiatry Physician
  • Philadelphia, PA
National Provider Identifier
1194138826
Registry record updated Jul 15, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
License
MD470050 Issued in PA
Practice address
100 E Lehigh Ave
Philadelphia, PA 19125-1012
Phone
(215) 707-8496
Fax
(215) 707-4086
NPI assigned
Jun 10, 2014
Sex
Female
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Jul 15, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatry Physician 2084P0800X MT207389 PA
Psychiatry Physician 2084P0800X MD470050 PA Primary

Addresses

Primary practice location

100 E Lehigh Ave
Philadelphia, PA 19125-1012

Mailing address

2450 W Hunting Park Ave
Philadelphia, PA 19129-1302
Phone (215) 707-3411

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20200721000179 PA Practitioner - Psychiatry 4981997715 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Psychiatry
Education
Other, 2014
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Temple Faculty Practice Plan IncGroup PAC ID 0345588711, 1,325 clinicians

Practice addresses (Care Compare)

100 E Lehigh Ave
Philadelphia, PA 19125-1012
Phone (215) 707-1800

Hospital & facility affiliations

  • Temple University Hospital Hospital, Philadelphia, PA, CCN 390027

Merit-based Incentive Payment System (MIPS)

Final score
81.21 of 100Reported as group
Quality
49.71
Promoting interoperability
100
Improvement activities
40
Cost
74.23

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
MD470050PAMDPsychiatry Physician
MT207389PAMDPsychiatry Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Temple Faculty Practice Plan, Inc CurrentSince Jul 1, 2020 Accepting new patients
Temple Faculty Practice Plan Inc CurrentSince Jul 1, 2020 Accepting new patients
Temple Faculty Practice Plan Inc Current Accepting new patients
Oakshore Psychiatry LLC Current Accepting new patients

Locations

2450 W Hunting Park Ave
Philadelphia, PA 19129
Phone (215) 707-2433

1316 W Ontario St
Philadelphia, PA 19140
Phone (215) 707-2400

3401 N Broad St
Philadelphia, PA 19140
Phone (215) 707-3807

100 E Lehigh Ave
Philadelphia, PA 19125
Phone (215) 707-1200

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 8

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1402358400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1594771200000",
    "number": "1194138826",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2450 W HUNTING PARK AVE",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191291302",
            "telephone_number": "215-707-3411"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 E LEHIGH AVE",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191251012",
            "telephone_number": "215-707-8496",
            "fax_number": "215-707-4086"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DIETZOLD",
        "first_name": "JACLYN",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2014-06-10",
        "last_updated": "2020-07-15",
        "certification_date": "2020-07-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "PA",
            "license": "MT207389",
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "PA",
            "license": "MD470050",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Philadelphia, PA

Sources for this page

Verify at the official NPI Registry.