Healthcare Provider Details

I. General information

NPI: 1780163469
Provider Name (Legal Business Name): HOLLY ANN JIMENEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2018
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9890 COUNTY FARM RD STE 3
RIVERSIDE CA
92503-3678
US

IV. Provider business mailing address

22445 ALESSANDRO BLVD # 113-114
MORENO VALLEY CA
92553-8358
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-2499
  • Fax:
Mailing address:
  • Phone: 951-788-8808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: