Provider Demographics
NPI:1497408686
Name:ENRIQUEZ-JIMENEZ, DIEGO (OT)
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:
Last Name:ENRIQUEZ-JIMENEZ
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22200 S GARDEN AVE
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-6065
Mailing Address - Country:US
Mailing Address - Phone:510-935-4388
Mailing Address - Fax:
Practice Address - Street 1:39159 PASEO PADRE PKWY
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1608
Practice Address - Country:US
Practice Address - Phone:510-730-2790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician