Healthcare Provider Details

I. General information

NPI: 1285243451
Provider Name (Legal Business Name): GABRIELLE MICHELLE JIMMERSON APCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17195 NEWHOPE ST STE 205
FOUNTAIN VALLEY CA
92708-4211
US

IV. Provider business mailing address

21951 RIMHURST DR UNIT J
LAKE FOREST CA
92630-5971
US

V. Phone/Fax

Practice location:
  • Phone: 657-360-4329
  • Fax:
Mailing address:
  • Phone: 575-921-5364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPCC6954
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: