Provider Demographics
NPI:1255787594
Name:JACKSON, DIANA YASHIEKA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:YASHIEKA
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 1:973 PORTLAND AVE
Mailing Address - Street 2:DOWNSTAIRS
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-4165
Mailing Address - Country:US
Mailing Address - Phone:585-953-2235
Mailing Address - Fax:
Practice Address - Street 1:973 PORTLAND AVE
Practice Address - Street 2:DOWNSTAIRS
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-4165
Practice Address - Country:US
Practice Address - Phone:585-953-2235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY324525-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse