Provider Demographics
NPI:1083837843
Name:JACKSON, DIANA MARIE (FNP)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 PENNOCK PL
Mailing Address - Street 2:SUITE 114
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3257
Mailing Address - Country:US
Mailing Address - Phone:970-495-8800
Mailing Address - Fax:
Practice Address - Street 1:1025 PENNOCK PL
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3257
Practice Address - Country:US
Practice Address - Phone:970-495-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA573806363L00000X
COAPN.0004850-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO41101359Medicaid
CO41101359Medicaid