Provider Demographics
NPI:1427321017
Name:DIAZ, JESSIBEL M (MA)
Entity type:Individual
Prefix:
First Name:JESSIBEL
Middle Name:M
Last Name:DIAZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB. LOS CAMINOS
Mailing Address - Street 2:CALLE AZALEA 97
Mailing Address - City:SAN LORENZO
Mailing Address - State:PR
Mailing Address - Zip Code:00754-9973
Mailing Address - Country:US
Mailing Address - Phone:787-702-1657
Mailing Address - Fax:
Practice Address - Street 1:REPARTO PINERO #20
Practice Address - Street 2:PISO 2, SUITE 201
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969
Practice Address - Country:US
Practice Address - Phone:787-702-1657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3750103T00000X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103T00000XBehavioral Health & Social Service ProvidersPsychologist