Provider Demographics
NPI:1487667143
Name:DIEBOLT, JEAN YOUNGSTROM (RN FNP)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:YOUNGSTROM
Last Name:DIEBOLT
Suffix:
Gender:F
Credentials:RN FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1584
Mailing Address - Street 2:
Mailing Address - City:CENTER
Mailing Address - State:TX
Mailing Address - Zip Code:75935-1584
Mailing Address - Country:US
Mailing Address - Phone:936-248-4673
Mailing Address - Fax:936-248-4646
Practice Address - Street 1:157 WALL ST
Practice Address - Street 2:
Practice Address - City:TENAHA
Practice Address - State:TX
Practice Address - Zip Code:75974-5413
Practice Address - Country:US
Practice Address - Phone:936-248-4673
Practice Address - Fax:936-248-4646
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX221153363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164735601Medicaid
TX164735601Medicaid
TXS64639Medicare UPIN