Healthcare Provider Details

I. General information

NPI: 1417498007
Provider Name (Legal Business Name): DIANA L JACKSON AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2017
Last Update Date: 03/24/2025
Certification Date: 03/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MAIN ST
LEWISTON ME
04240-7027
US

IV. Provider business mailing address

300 MAIN ST
LEWISTON ME
04240-7027
US

V. Phone/Fax

Practice location:
  • Phone: 207-795-7575
  • Fax: 207-795-7133
Mailing address:
  • Phone: 207-795-7575
  • Fax: 207-795-7133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberCNP171007
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberCNP171007
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP171007
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: