Provider Demographics
NPI:1740094853
Name:JACKSON, DIAMOND MARSHELL-DESAREE'
Entity type:Individual
Prefix:
First Name:DIAMOND
Middle Name:MARSHELL-DESAREE'
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 1:6317 N 24TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68110-1023
Mailing Address - Country:US
Mailing Address - Phone:402-739-1087
Mailing Address - Fax:
Practice Address - Street 1:14210 ARBOR ST STE A
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-2382
Practice Address - Country:US
Practice Address - Phone:531-999-1133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-07
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant