Healthcare Provider Details

I. General information

NPI: 1235266883
Provider Name (Legal Business Name): JIMMIE ALLEN POWELL MFT24610
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83912 AVENUE 45 STE 9
INDIO CA
92201-3338
US

IV. Provider business mailing address

72629 SKYWARD WAY
PALM DESERT CA
92260-6023
US

V. Phone/Fax

Practice location:
  • Phone: 760-347-0754
  • Fax: 760-347-8507
Mailing address:
  • Phone: 760-674-1529
  • Fax: 760-347-0754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT24610
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: