Provider Demographics
NPI:1508040049
Name:DIAZ, JESSICA (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 COLLINS AVE
Mailing Address - Street 2:APARTMENT 526
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33140-2573
Mailing Address - Country:US
Mailing Address - Phone:305-401-1755
Mailing Address - Fax:
Practice Address - Street 1:5401 COLLINS AVE
Practice Address - Street 2:APARTMENT 526
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-2573
Practice Address - Country:US
Practice Address - Phone:305-401-1755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8858235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist