Individual
JACKSON RAY DIEDE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MAT, ATC
Contact information
Practice address
810 E 23RD ST, SIOUX FALLS, SD 57105-2135
(605) 331-5890
Mailing address
117 S HIGH ST, MENNO, SD 57045-2170
(605) 760-1566
Taxonomy
Speciality
Code
Description
License number
State
2081S0010X
Sports Medicine (Physical Medicine & Rehabilitation) Physician
Primary
0714
SD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
WSLW01080864
BLUECROSS BLUESHIELD
SD
Enumeration date
07/13/2021
Last updated
07/13/2021
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