MEDICARE: ANDRES REYNOSO JIMENEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor		CA

General Provider Information

NPI Number	:	1134085624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDRES REYNOSO JIMENEZ

Provider Business Mailing Address
First Line	:	1400 N JOHNSON AVE STE 101
Second Line	:
City	:	EL CAJON
State	:	CA
Zip	:	92020-1651
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1180 3RD AVE STE C3
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91911-3139
Country	:	US
Telephone Number	:	619-691-8164
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2025
Last Update Date	:	12/29/2025

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