Healthcare Provider Details

I. General information

NPI: 1053254060
Provider Name (Legal Business Name): VIVIAN GUADALUPE JIMENEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4260 54TH ST
SAN DIEGO CA
92115-6009
US

IV. Provider business mailing address

4260 54TH ST
SAN DIEGO CA
92115-6009
US

V. Phone/Fax

Practice location:
  • Phone: 619-795-3137
  • Fax:
Mailing address:
  • Phone: 619-795-3137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number250164529
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: