MEDICARE: MS. VANESSA JIMENEZ RICHARDSON MFT

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	A013490315	CA
2	106H00000X	Marriage & Family Therapist	LMFT96334	CA

General Provider Information

NPI Number	:	1295201812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VANESSA JIMENEZ RICHARDSON MFT

Provider Business Mailing Address
First Line	:	13106 CLAREMONT AVE
Second Line	:
City	:	VICTORVILLE
State	:	CA
Zip	:	92392-7225
Country	:	US
Telephone Number	:	949-302-3793
Fax Number	:

Provider Business Practice Location Address
First Line	:	18077 OUTER HWY 18
Second Line	:
City	:	APPLE VALLEY
State	:	CA
Zip	:	92307-2197
Country	:	US
Telephone Number	:	760-949-1228
Fax Number	:

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

Provider Enumeration Date	:	10/22/2018
Last Update Date	:	10/22/2018

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