Provider Demographics
NPI:1194413617
Name:DIAZ, JESSICA DENISE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:DENISE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 SPRUCE ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507
Mailing Address - Country:US
Mailing Address - Phone:951-357-6926
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:1650 SPRUCE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507
Practice Address - Country:US
Practice Address - Phone:951-357-6926
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician