Healthcare Provider Details

I. General information

NPI: 1952893455
Provider Name (Legal Business Name): SARAH JIMENEZ MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARAH LATOSKI

II. Dates (important events)

Enumeration Date: 05/31/2018
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3981 CHARLES ST
LA MESA CA
91941-7516
US

IV. Provider business mailing address

130 CORRIDOR RD UNIT 3292
PONTE VEDRA BEACH FL
32004-7833
US

V. Phone/Fax

Practice location:
  • Phone: 619-400-9574
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-35000
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: