Active NPI
Jaime Dietzen, LCSW
- Clinical Social Worker
- Bentonville, AR
National Provider Identifier
1477833762
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Social Worker
- License
- 60577
- Practice address
- 2003 SE Walton Blvd
Bentonville, AR 72712-3725 - Phone
- (479) 464-5925
- Fax
- (479) 464-4275
- NPI assigned
- Aug 18, 2011
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Social Worker | 1041C0700X | 60577 | TX | Primary |
Addresses
Primary practice location
2003 SE Walton Blvd
Bentonville, AR 72712-3725
Mailing address
2458 Siskiyou St
Lewisville, TX 75056-6790
Phone (972) 743-4416
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 60577 | TX | MD | Clinical Social Worker |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1313625600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1626134400000",
"number": "1477833762",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2458 SISKIYOU ST",
"city": "LEWISVILLE",
"state": "TX",
"postal_code": "750566790",
"telephone_number": "972-743-4416"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2003 SE WALTON BLVD",
"city": "BENTONVILLE",
"state": "AR",
"postal_code": "727123725",
"telephone_number": "479-464-5925",
"fax_number": "479-464-4275"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DIETZEN",
"first_name": "JAIME",
"name_prefix": "Mrs.",
"credential": "LCSW",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2011-08-18",
"last_updated": "2021-07-13",
"certification_date": "2021-07-13",
"status": "A"
},
"taxonomies": [
{
"code": "1041C0700X",
"taxonomy_group": "",
"desc": "Social Worker, Clinical",
"state": "TX",
"license": "60577",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Bentonville, AR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 13, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.