Provider Demographics
NPI:1053183004
Name:MEDINA, JANNA PATRICIA DIAMSE (RBT)
Entity type:Individual
Prefix:
First Name:JANNA PATRICIA
Middle Name:DIAMSE
Last Name:MEDINA
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5045 MADEIRA RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-3956
Mailing Address - Country:US
Mailing Address - Phone:757-339-4198
Mailing Address - Fax:757-561-2627
Practice Address - Street 1:5045 MADEIRA RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-3956
Practice Address - Country:US
Practice Address - Phone:757-339-4198
Practice Address - Fax:757-561-2627
Is Sole Proprietor?:No
Enumeration Date:2023-10-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VARBT-20-133430106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician