Provider Demographics
NPI:1952129785
Name:DIAZ MANZANO, JENYFER
Entity type:Individual
Prefix:
First Name:JENYFER
Middle Name:
Last Name:DIAZ MANZANO
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 1:1623 W 23RD ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92411-1155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:560 E HOSPITALITY LN STE 400
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3545
Practice Address - Country:US
Practice Address - Phone:909-891-1599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical