Healthcare Provider Details

I. General information

NPI: 1548876196
Provider Name (Legal Business Name): JENNIFER DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2020
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 MAITLAND AVE
ALTAMONTE SPRINGS FL
32701-6834
US

IV. Provider business mailing address

632 MAITLAND AVE
ALTAMONTE SPRINGS FL
32701-6834
US

V. Phone/Fax

Practice location:
  • Phone: 407-875-5704
  • Fax:
Mailing address:
  • Phone: 407-875-5704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMT3002
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: