Provider Demographics
NPI:1366841306
Name:DIAZ, JESSICA LISBET (LCSW97835)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LISBET
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LCSW97835
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 W VICTORIA ST STE F&G
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90220-5807
Mailing Address - Country:US
Mailing Address - Phone:310-707-2820
Mailing Address - Fax:310-669-9501
Practice Address - Street 1:901 W VICTORIA ST. SUITE F & G
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90220
Practice Address - Country:US
Practice Address - Phone:310-707-2820
Practice Address - Fax:310-669-9501
Is Sole Proprietor?:No
Enumeration Date:2014-08-15
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW67504101YM0800X
LCSW97835101YM0800X
390200000X
CALCSW978351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YM0800XMedicaid