Healthcare Provider Details

I. General information

NPI: 1699630202
Provider Name (Legal Business Name): JENNIFER DIAZ LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 02/22/2026
Certification Date: 02/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9846 LIBERTY RD
RANDALLSTOWN MD
21133-2007
US

IV. Provider business mailing address

9846 LIBERTY RD
RANDALLSTOWN MD
21133-2007
US

V. Phone/Fax

Practice location:
  • Phone: 240-389-3484
  • Fax:
Mailing address:
  • Phone: 240-389-3484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number34169
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: