Provider Demographics
NPI:1073817318
Name:JACKSON, DIANE (FNP-BC, MSN, BSN, RN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP-BC, MSN, BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25329 I-45
Mailing Address - Street 2:SUITE B
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380
Mailing Address - Country:US
Mailing Address - Phone:281-292-3030
Mailing Address - Fax:
Practice Address - Street 1:25329 I-45
Practice Address - Street 2:SUITE B
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380
Practice Address - Country:US
Practice Address - Phone:281-292-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-30
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX792726363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily