Provider Demographics
NPI:1962479774
Name:THACKER, JEANNE DIANE (MSN CNS, FNP-C)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:DIANE
Last Name:THACKER
Suffix:
Gender:F
Credentials:MSN CNS, FNP-C
Other - Prefix:
Other - First Name:JEANNE
Other - Middle Name:DIANE
Other - Last Name:THACKER-ANDRADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN CNS, FNP-C
Mailing Address - Street 1:1050 STATE HIGHWAY 16 S
Mailing Address - Street 2:
Mailing Address - City:BANDERA
Mailing Address - State:TX
Mailing Address - Zip Code:78003-4830
Mailing Address - Country:US
Mailing Address - Phone:830-796-7713
Mailing Address - Fax:
Practice Address - Street 1:1050 STATE HIGHWAY 16 S
Practice Address - Street 2:
Practice Address - City:BANDERA
Practice Address - State:TX
Practice Address - Zip Code:78003-4830
Practice Address - Country:US
Practice Address - Phone:830-796-7713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX573554363LF0000X, 364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1962479774OtherNPI
8D0453OtherMEDICARE PROVIDER NUMBER ISSUED BY CMS 1/2005
TX1962479774OtherNPI
8B4555Medicare ID - Type Unspecified