Provider Demographics
NPI:1881035772
Name:DIAZ, JENNIFER (LMT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3429 ANDRITA ST
Mailing Address - Street 2:1
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90065-2952
Mailing Address - Country:US
Mailing Address - Phone:323-605-6055
Mailing Address - Fax:
Practice Address - Street 1:3429 ANDRITA ST
Practice Address - Street 2:1
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90065-2952
Practice Address - Country:US
Practice Address - Phone:323-605-6055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1227225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist