Healthcare Provider Details

I. General information

NPI: 1720382716
Provider Name (Legal Business Name): OCTAVIO F JIMENEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2011
Last Update Date: 01/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N 9TH ST SUITE B
MODESTO CA
95350-5814
US

IV. Provider business mailing address

706 JEFFREY RD
LOS BANOS CA
93635-3816
US

V. Phone/Fax

Practice location:
  • Phone: 209-341-1824
  • Fax:
Mailing address:
  • Phone: 209-675-3899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: