Provider Demographics
NPI:1043077662
Name:DIAZ, JESUS
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 AMBER LOOP
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901-6111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 LINK RD
Practice Address - Street 2:
Practice Address - City:NACHES
Practice Address - State:WA
Practice Address - Zip Code:98937-9608
Practice Address - Country:US
Practice Address - Phone:509-966-5880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health