Provider Demographics
NPI:1619435021
Name:DIESERU, JACOB S
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:S
Last Name:DIESERU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3740 RAMONA DR APT B
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-7070
Mailing Address - Country:US
Mailing Address - Phone:682-360-1115
Mailing Address - Fax:
Practice Address - Street 1:3740 RAMONA DR APT B
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-7070
Practice Address - Country:US
Practice Address - Phone:682-360-1115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide