Individual
DR. JESSICA MARIE DIETHELM
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
1725 W HARRISON ST, SUITE 263, CHICAGO, IL 60612-3841
(312) 942-6700
(312) 942-3633
Mailing address
1725 W HARRISON ST, SUITE 263, CHICAGO, IL 60612-3841
(312) 942-6700
(312) 942-3633
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
036118681
IL
208000000X
Pediatrics Physician
036118681
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036118681
—
IL
Enumeration date
12/26/2007
Last updated
05/04/2011
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