Provider Demographics
NPI:1457543183
Name:JAKINS, DIANE C (ACNP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:C
Last Name:JAKINS
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SECURITY SQ
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-1932
Mailing Address - Country:US
Mailing Address - Phone:228-865-1330
Mailing Address - Fax:228-865-1331
Practice Address - Street 1:400 SECURITY SQ
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507-1932
Practice Address - Country:US
Practice Address - Phone:228-865-1330
Practice Address - Fax:228-865-1331
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR772563363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01282761Medicaid
MS512I500107Medicare PIN