Healthcare Provider Details

I. General information

NPI: 1053673301
Provider Name (Legal Business Name): JIMMY DON HARGROVE MFTI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72710 E LYNN ST
THOUSAND PALMS CA
92276-3312
US

IV. Provider business mailing address

34538 DOUBLE DIAMOND DR
THOUSAND PALMS CA
92276-4107
US

V. Phone/Fax

Practice location:
  • Phone: 760-343-3211
  • Fax:
Mailing address:
  • Phone: 760-702-1715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number66850
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: