Provider Demographics
NPI:1033687694
Name:JWAINAT, DIA
Entity Type:Individual
Prefix:
First Name:DIA
Middle Name:
Last Name:JWAINAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 W 7 MILE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203-1967
Mailing Address - Country:US
Mailing Address - Phone:313-893-6172
Mailing Address - Fax:313-893-0064
Practice Address - Street 1:62 W 7 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-1967
Practice Address - Country:US
Practice Address - Phone:313-893-6172
Practice Address - Fax:313-893-0064
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3434247Medicaid