=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609498542
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL SCOTT JIMMERSON APCC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2020
-----------------------------------------------------
Last Update Date | 01/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20331 FLANAGAN ROAD
-----------------------------------------------------
City | TRABUCO CANYON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-582-8832
-----------------------------------------------------
Fax | 818-582-8836
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21951 RIMHURST DR UNIT J
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92630-5971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-566-5039
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | APCC9046
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------