Provider Demographics
NPI:1003432576
Name:DIEHL, JESSICA (APRN)
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:
Last Name:DIEHL
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 LEGACY PLZ W
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-5254
Mailing Address - Country:US
Mailing Address - Phone:219-575-7578
Mailing Address - Fax:219-575-7186
Practice Address - Street 1:500 LEGACY PLZ W
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-5254
Practice Address - Country:US
Practice Address - Phone:219-575-7578
Practice Address - Fax:219-575-7186
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11007660363L00000X, 363LA2200X
IN71015029A363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9PSOVOtherBCBS
FL107241700Medicaid