Healthcare Provider Details

I. General information

NPI: 1548944069
Provider Name (Legal Business Name): REY PAOLO ERNESTO JIMENEZ ROCA III MSN, RN, CNE, PMHPHN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14608 GRAYSTONE AVE
NORWALK CA
90650-5601
US

IV. Provider business mailing address

14608 GRAYSTONE AVE
NORWALK CA
90650-5601
US

V. Phone/Fax

Practice location:
  • Phone: 714-494-3090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number95241249
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: