Healthcare Provider Details

I. General information

NPI: 1114768280
Provider Name (Legal Business Name): PHOENIX JETT-DIAS
Entity Type: Individual
Gender:
Sole Proprietor: Y

Provider Other Name: PHOENIX JETT-DIAS

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 TULLY RD
MODESTO CA
95350-0836
US

IV. Provider business mailing address

3300 TULLY RD STE B6
MODESTO CA
95350-0848
US

V. Phone/Fax

Practice location:
  • Phone: 209-585-0555
  • Fax: 209-596-5142
Mailing address:
  • Phone: 209-585-0555
  • Fax: 209-596-5142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: