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General NPI Number Information
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NPI Number | 1114768280
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Entity Type | Individual
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Provider Name | PHOENIX JETT-DIAS
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Gender |
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Dates
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Enumeration Date | 06/03/2024
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Last Update Date | 07/25/2025
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Provider Practice Location Address
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Address Line | 3300 TULLY RD
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City | MODESTO
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State | CA
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Zip | 95350-0836
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Country | US
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Telephone | 209-585-0555
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Fax | 209-596-5142
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Provider Business Mailing Address
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Address Line | 3300 TULLY RD STE B6
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City | MODESTO
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State | CA
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Zip | 95350-0848
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Country | US
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Telephone | 209-585-0555
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Fax | 209-596-5142
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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