Basic Information
| Provider Information | |||||||||
| NPI: | 1023075116 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | DIECKMAN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | 9376194231 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 N PICKAWAY ST | ||||||||
| Address2: | |||||||||
| City: | CIRCLEVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431132409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404742126 | ||||||||
| FaxNumber: | 7404771022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 08/06/2013 | ||||||||
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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 | 207P00000X | 34003715M | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000316758 | 01 | OH | BCBS | OTHER | P00093121 | 01 | OH | RR MEDICARE | OTHER | 0937053 | 05 | OH | MEDICAID |