Provider Demographics
NPI:1871376012
Name:HERNANDEZ DIAZ, JESUS ELIAS
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:ELIAS
Last Name:HERNANDEZ DIAZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 NW 25TH ST STE 5E
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33172-1416
Mailing Address - Country:US
Mailing Address - Phone:888-527-8037
Mailing Address - Fax:
Practice Address - Street 1:5100 W KENNEDY BLVD STE 160
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-1817
Practice Address - Country:US
Practice Address - Phone:888-527-8037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-287395106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician