Provider Demographics
NPI:1174104756
Name:MACK, DIAMOND JACKLYN (BACHELOR'S IN ART)
Entity type:Individual
Prefix:
First Name:DIAMOND
Middle Name:JACKLYN
Last Name:MACK
Suffix:
Gender:F
Credentials:BACHELOR'S IN ART
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 CAPOBIANCO PLZ APT D
Mailing Address - Street 2:
Mailing Address - City:RAHWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07065-5419
Mailing Address - Country:US
Mailing Address - Phone:908-463-5621
Mailing Address - Fax:
Practice Address - Street 1:560 CAPOBIANCO PLZ APT D
Practice Address - Street 2:
Practice Address - City:RAHWAY
Practice Address - State:NJ
Practice Address - Zip Code:07065-5419
Practice Address - Country:US
Practice Address - Phone:908-463-5621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst