Basic Information
| Provider Information | |||||||||
| NPI: | 1386610822 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOBSON | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | R.N.,C.P.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2152 S VINEYARD | ||||||||
| Address2: | SUITE 129 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852106871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807320044 | ||||||||
| FaxNumber: | 4807329333 | ||||||||
| Practice Location | |||||||||
| Address1: | 2152 S VINEYARD | ||||||||
| Address2: | SUITE 129 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852106871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807320044 | ||||||||
| FaxNumber: | 4807329333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 12/01/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | R.N.042819 PNP124 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 431528 | 05 | AZ | MEDICAID |