Provider Demographics
NPI:1760609184
Name:JACKSON, DIANNA M
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9251 HOOKER ST
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80031-2726
Mailing Address - Country:US
Mailing Address - Phone:720-890-7686
Mailing Address - Fax:
Practice Address - Street 1:280 EXEMPLA CIR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-3370
Practice Address - Country:US
Practice Address - Phone:303-861-3408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
015964OtherKAISER-COMMERCIAL NUMBER