Provider Demographics
NPI:1063768521
Name:JACKSON, DIANE MARIE (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12517 ERWIN AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44135-3554
Mailing Address - Country:US
Mailing Address - Phone:216-507-1400
Mailing Address - Fax:
Practice Address - Street 1:12517 ERWIN AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44135-3554
Practice Address - Country:US
Practice Address - Phone:216-507-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-01
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.370239163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse