=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497250526
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXIS JIMENEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2018
-----------------------------------------------------
Last Update Date | 03/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20212 REDWOOD RD
-----------------------------------------------------
City | CASTRO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94546-4324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-422-2090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 516 CARTMELL WAY
-----------------------------------------------------
City | MERCED
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95341-6800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-628-5464
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-17-44197
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------