Basic Information
| Provider Information | |||||||||
| NPI: | 1467841619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JIMENEZ | ||||||||
| FirstName: | LENER | ||||||||
| MiddleName: | ORIFILIO | ||||||||
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| Credential: | ACSW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2640 INDUSTRY WAY | ||||||||
| Address2: | |||||||||
| City: | LYNWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902624284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106274525 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2640 INDUSTRY WAY | ||||||||
| Address2: | |||||||||
| City: | LYNWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902624284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106274525 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2015 | ||||||||
| LastUpdateDate: | 09/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 89134 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YM0800X | 36507 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 89134 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1467841619 | 05 | CA | MEDICAID | 101YM0800X | 01 | CA | DMH | OTHER | 101YM0800X | 01 | CA | MEDICAL | OTHER |