MEDICARE: JESSICA DIAMOND

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1043686025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA DIAMOND

Provider Business Mailing Address
First Line	:	3637 W WAHALLA LN
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-2236
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3637 W WAHALLA LN
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-2236
Country	:	US
Telephone Number	:	623-556-6655
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2015
Last Update Date	:	08/13/2015

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Directions to “ JESSICA DIAMOND ” Practice Location

Language	Start Address	Practice Location

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