Provider Demographics
NPI:1093520108
Name:JACKSON, DIAMOND MONE (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:DIAMOND
Middle Name:MONE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 W PETTIGREW ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-4821
Mailing Address - Country:US
Mailing Address - Phone:919-286-0751
Mailing Address - Fax:
Practice Address - Street 1:1515 W PETTIGREW ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4821
Practice Address - Country:US
Practice Address - Phone:919-286-0751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-07
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP23816225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist