Provider Demographics
NPI:1619100203
Name:JACKMAN, DIANE KAY (LPN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:KAY
Last Name:JACKMAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9336 TOWNSHIP HIGHWAY 121
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-9797
Mailing Address - Country:US
Mailing Address - Phone:740-360-0954
Mailing Address - Fax:
Practice Address - Street 1:9336 TOWNSHIP HIGHWAY 121
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-9797
Practice Address - Country:US
Practice Address - Phone:740-360-0954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-28
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN088124164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse