Healthcare Provider Details

I. General information

NPI: 1588265912
Provider Name (Legal Business Name): JENNY ALICIA JIMENEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20353 GUFFY LN
WILDOMAR CA
92595-8797
US

IV. Provider business mailing address

20353 GUFFY LN
WILDOMAR CA
92595-8797
US

V. Phone/Fax

Practice location:
  • Phone: 951-228-6985
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: