Provider Demographics
NPI:1861016735
Name:DIEFENBACH, JESSICA A (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:A
Last Name:DIEFENBACH
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4209 W INDIGO WAY
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-8228
Mailing Address - Country:US
Mailing Address - Phone:760-731-0313
Mailing Address - Fax:951-587-8277
Practice Address - Street 1:4209 W INDIGO WAY
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-8228
Practice Address - Country:US
Practice Address - Phone:760-731-0313
Practice Address - Fax:951-587-8277
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ276424363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner