Provider Demographics
NPI:1336811512
Name:DIAZ, JACKELINE MARIA
Entity type:Individual
Prefix:
First Name:JACKELINE
Middle Name:MARIA
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 1:12325NW 23AVE MIAMI FL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33167
Mailing Address - Country:US
Mailing Address - Phone:678-227-9163
Mailing Address - Fax:
Practice Address - Street 1:12325NW 23AVE MIAMI FL
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33167
Practice Address - Country:US
Practice Address - Phone:678-227-9163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-128232106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician