Provider Demographics
NPI:1467796128
Name:JACKSON, DIANE REGINA (ARNP)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:REGINA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27038 SEA BREEZE WAY
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33544-6617
Mailing Address - Country:US
Mailing Address - Phone:813-516-0679
Mailing Address - Fax:
Practice Address - Street 1:1248 E HILLSBOROUGH AVE
Practice Address - Street 2:221
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-7201
Practice Address - Country:US
Practice Address - Phone:813-516-0679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-19
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2121402363LP2300X, 364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health