Healthcare Provider Details

I. General information

NPI: 1952142770
Provider Name (Legal Business Name): JIMINI HEALTH PSYCHOLOGY PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

548 GERONA RD
STANFORD CA
94305-8449
US

IV. Provider business mailing address

548 GERONA RD
STANFORD CA
94305-8449
US

V. Phone/Fax

Practice location:
  • Phone: 786-247-3983
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CHIARA WAINGARTEN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 786-247-3983