Healthcare Provider Details

I. General information

NPI: 1649766692
Provider Name (Legal Business Name): JACQUELINE JIMENEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 E PENN ST
SAN DIMAS CA
91773-1132
US

IV. Provider business mailing address

128 E PENN ST
SAN DIMAS CA
91773-1132
US

V. Phone/Fax

Practice location:
  • Phone: 626-230-3142
  • Fax:
Mailing address:
  • Phone: 626-230-3142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number150980
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: