Healthcare Provider Details

I. General information

NPI: 1982872859
Provider Name (Legal Business Name): MARTHA CATALINA JIMENEZ MFT INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 03/28/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8174 WESTPORT CIR
DISCOVERY BAY CA
94505-2680
US

IV. Provider business mailing address

PO BOX 1096
DISCOVERY BAY CA
94505-7096
US

V. Phone/Fax

Practice location:
  • Phone: 310-480-8758
  • Fax:
Mailing address:
  • Phone: 310-480-8758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF 55799
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: