Provider Demographics
NPI:1184282303
Name:DIAZ, JESSICA (LCPC, NCC, ICADC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LCPC, NCC, ICADC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:HINKLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:711 E PORTER ST
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-1484
Mailing Address - Country:US
Mailing Address - Phone:208-813-4431
Mailing Address - Fax:208-922-3778
Practice Address - Street 1:711 E PORTER ST
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-1484
Practice Address - Country:US
Practice Address - Phone:208-813-4431
Practice Address - Fax:208-922-3778
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-8096101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health