Provider Demographics
NPI:1114768280
Name:JETT-DIAS, PHOENIX
Entity type:Individual
Prefix:
First Name:PHOENIX
Middle Name:
Last Name:JETT-DIAS
Suffix:
Gender:U
Credentials:
Other - Prefix:
Other - First Name:PHOENIX
Other - Middle Name:
Other - Last Name:JETT-DIAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3300 TULLY RD STE B6
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-0848
Mailing Address - Country:US
Mailing Address - Phone:209-585-0555
Mailing Address - Fax:209-596-5142
Practice Address - Street 1:3300 TULLY RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-0836
Practice Address - Country:US
Practice Address - Phone:209-585-0555
Practice Address - Fax:209-596-5142
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No174400000XOther Service ProvidersSpecialist
No175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator