Provider Demographics
NPI:1265209811
Name:DIAZ, JESSICA LIZMARIE (CHW00838)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LIZMARIE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:CHW00838
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ASYLUM ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757-2203
Mailing Address - Country:US
Mailing Address - Phone:774-489-2304
Mailing Address - Fax:
Practice Address - Street 1:10 ASYLUM ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-2203
Practice Address - Country:US
Practice Address - Phone:774-489-2304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-05
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MACHW00838172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker