Healthcare Provider Details

I. General information

NPI: 1184271454
Provider Name (Legal Business Name): MARISOL JIMENEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 S MEDNIK AVE # 201
LOS ANGELES CA
90022-1606
US

IV. Provider business mailing address

900 CORPORATE CENTER DR STE 350
MONTEREY PARK CA
91754-7620
US

V. Phone/Fax

Practice location:
  • Phone: 323-981-9714
  • Fax: 323-981-9715
Mailing address:
  • Phone: 323-562-4016
  • Fax: 323-562-4096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: