1164662276 NPI number — JESSICA H DIEKHOFF APRN, BC

Table of content: JESSICA H DIEKHOFF APRN, BC (NPI 1164662276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164662276 NPI number — JESSICA H DIEKHOFF APRN, BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIEKHOFF
Provider First Name:
JESSICA
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN, BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HIPSKY
Provider Other First Name:
JESSICA
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1164662276
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12855 N FORTY DR
Provider Second Line Business Mailing Address:
STE 280
Provider Business Mailing Address City Name:
ST. LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-432-4415
Provider Business Mailing Address Fax Number:
314-432-1986

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12855 N FORTY DR
Provider Second Line Business Practice Location Address:
STE 280
Provider Business Practice Location Address City Name:
ST. LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-432-4415
Provider Business Practice Location Address Fax Number:
314-432-1986
Provider Enumeration Date:
03/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  140356 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P01134602 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1164662276 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: P22480 . This is a "UPIN" identifier . This identifiers is of the category "OTHER".




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