Provider Demographics
NPI:1164662276
Name:DIEKHOFF, JESSICA H (APRN, BC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:H
Last Name:DIEKHOFF
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:R
Other - Last Name:HIPSKY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12855 N FORTY DR
Mailing Address - Street 2:STE 280
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-432-4415
Mailing Address - Fax:314-432-1986
Practice Address - Street 1:12855 N FORTY DR
Practice Address - Street 2:STE 280
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-432-4415
Practice Address - Fax:314-432-1986
Is Sole Proprietor?:No
Enumeration Date:2009-03-02
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO140356363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01134602OtherRAILROAD MEDICARE
MO1164662276Medicaid
P22480OtherUPIN
MOMA152800092Medicare PIN