Provider Demographics
NPI:1922070655
Name:JACKSON, DIANNE (NP)
Entity Type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:DIANNE
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-C
Mailing Address - Street 1:507 JOHN R BLVD
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-2443
Mailing Address - Country:US
Mailing Address - Phone:573-471-7113
Mailing Address - Fax:
Practice Address - Street 1:5250 NEW JERSEY AVE
Practice Address - Street 2:
Practice Address - City:FORT DIX
Practice Address - State:NJ
Practice Address - Zip Code:08640-5017
Practice Address - Country:US
Practice Address - Phone:609-562-6965
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO098462363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily