Healthcare Provider Details

I. General information

NPI: 1417017971
Provider Name (Legal Business Name): IRENE - JIMENEZ RN,PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: IRENE - JIMENEZ REGISTERED NURSE

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 BECK AVE
FAIRFIELD CA
94533-6804
US

IV. Provider business mailing address

8708 PACIFIC HILLS WAY
SACRAMENTO CA
95828-5123
US

V. Phone/Fax

Practice location:
  • Phone: 707-784-8650
  • Fax: 707-421-7484
Mailing address:
  • Phone: 916-689-2056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number288830
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: