Provider Demographics
NPI:1104216902
Name:DIEZ, JESSICA (LCPC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DIEZ
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:MACHIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12501 PROSPERITY DR STE 310
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-1699
Mailing Address - Country:US
Mailing Address - Phone:402-780-8884
Mailing Address - Fax:
Practice Address - Street 1:12501 PROSPERITY DR STE 310
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-1699
Practice Address - Country:US
Practice Address - Phone:240-780-8884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-31
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC6087101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional