Healthcare Provider Details

I. General information

NPI: 1508790205
Provider Name (Legal Business Name): CASSANDRA FONSECA JIMENEZ SUDCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CASSANDRA JIMENEZ SUDCC

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 P MENDOZA ST
CALEXICO CA
92231-3608
US

IV. Provider business mailing address

1024 P MENDOZA ST
CALEXICO CA
92231-3608
US

V. Phone/Fax

Practice location:
  • Phone: 858-208-0121
  • Fax:
Mailing address:
  • Phone: 858-208-0121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number9493
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: