Healthcare Provider Details

I. General information

NPI: 1871001578
Provider Name (Legal Business Name): JOSE JIMENEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25910 ACERO STE 160
MISSION VIEJO CA
92691-2777
US

IV. Provider business mailing address

1461 E COOLEY DR STE 100
COLTON CA
92324-3921
US

V. Phone/Fax

Practice location:
  • Phone: 877-522-7187
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number142600
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: