Provider Demographics
NPI:1639931942
Name:DIAZ DIAZ, JERDA (BEHAVIOR TECHNICIAN)
Entity Type:Individual
Prefix:
First Name:JERDA
Middle Name:
Last Name:DIAZ DIAZ
Suffix:
Gender:F
Credentials:BEHAVIOR TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 S SUSSEX DR
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-4743
Mailing Address - Country:US
Mailing Address - Phone:919-901-2823
Mailing Address - Fax:
Practice Address - Street 1:45 S SUSSEX DR
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-4743
Practice Address - Country:US
Practice Address - Phone:919-901-2823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-23
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20-111614106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician