Healthcare Provider Details

I. General information

NPI: 1508998600
Provider Name (Legal Business Name): JENNIFER LYNN DIEKMANN BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER LYNN FORRESTER-THOMAS BSN

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 N WASHINGTON ST
COUNCIL GROVE KS
66846-1422
US

IV. Provider business mailing address

600 N WASHINGTON ST
COUNCIL GROVE KS
66846-1499
US

V. Phone/Fax

Practice location:
  • Phone: 620-767-5126
  • Fax: 620-767-6910
Mailing address:
  • Phone: 620-767-6811
  • Fax: 620-767-5611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1493418051
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number93418
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: