Provider Demographics
NPI:1750052064
Name:GOMEZ DIAZ, JESSICA C
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:C
Last Name:GOMEZ DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13376 SW 46TH LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-3929
Mailing Address - Country:US
Mailing Address - Phone:786-451-7411
Mailing Address - Fax:
Practice Address - Street 1:13376 SW 46TH LN
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3929
Practice Address - Country:US
Practice Address - Phone:786-451-7411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-26
Last Update Date:2021-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-125894106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty