Provider Demographics
NPI:1225247752
Name:JACKSON, DIANA DEAN (MS)
Entity Type:Individual
Prefix:MISS
First Name:DIANA
Middle Name:DEAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MRS
Other - First Name:DIANA
Other - Middle Name:DEAN
Other - Last Name:JACKSON-BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:6133 ELM LN
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-1321
Mailing Address - Country:US
Mailing Address - Phone:708-720-1621
Mailing Address - Fax:708-720-1621
Practice Address - Street 1:6133 ELM LN
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-1321
Practice Address - Country:US
Practice Address - Phone:708-720-1621
Practice Address - Fax:708-720-1621
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist