Healthcare Provider Details

I. General information

NPI: 1629552013
Provider Name (Legal Business Name): STAPHANY JIMENEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 ALVARADO AVE
DAVIS CA
95616-5521
US

IV. Provider business mailing address

2745 ORCHARD LN APT 13206
SACRAMENTO CA
95833-3961
US

V. Phone/Fax

Practice location:
  • Phone: 530-756-0700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT27267
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: