MEDICARE: JIMNA SARAHI MENDOZA DE PENA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	390200000X	CA
2	101YM0800X	Mental Health Counselor	111405	CA

General Provider Information

NPI Number	:	1831771328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JIMNA SARAHI MENDOZA DE PENA

Provider Business Mailing Address
First Line	:	669 W 34TH ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90089-0067
Country	:	US
Telephone Number	:	866-740-6502
Fax Number	:

Provider Business Practice Location Address
First Line	:	669 W 34TH ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90089-2211
Country	:	US
Telephone Number	:	866-740-6502
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2021
Last Update Date	:	01/24/2024

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