MEDICARE: MS. DIANE REGINA JACKSON ARNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner	ARNP2121402	FL
2	364SA2200X	Adult Health Clinical Nurse Specialist	ARNP2121402	FL

General Provider Information

NPI Number	:	1467796128
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANE REGINA JACKSON ARNP

Provider Business Mailing Address
First Line	:	27038 SEA BREEZE WAY
Second Line	:
City	:	ZEPHYRHILLS
State	:	FL
Zip	:	33544-6617
Country	:	US
Telephone Number	:	813-516-0679
Fax Number	:

Provider Business Practice Location Address
First Line	:	1248 E HILLSBOROUGH AVE
Second Line	:	221
City	:	TAMPA
State	:	FL
Zip	:	33604-7201
Country	:	US
Telephone Number	:	813-516-0679
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/19/2012
Last Update Date	:	11/20/2014

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