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NPI Code Detail

MEDICARE: MRS. DIANNE JACKSON NP

MEDICARE: MRS. DIANNE JACKSON NP
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
1363LF0000XFamily Nurse Practitioner098462MO

General Provider Information

NPI Number : 1922070655
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. DIANNE JACKSON NP
Provider Business Mailing Address
First Line : 507 JOHN R BLVD
Second Line :
City : SIKESTON
State : MO
Zip : 63801-2443
Country : US
Telephone Number : 573-471-7113
Fax Number :
Provider Business Practice Location Address
First Line : 5250 NEW JERSEY AVE
Second Line :
City : FORT DIX
State : NJ
Zip : 08640-5017
Country : US
Telephone Number : 609-562-6965
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/06/2006
Last Update Date : 07/08/2007

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