Basic Information
| Provider Information | |||||||||
| NPI: | 1790800381 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JIMENEZ | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | CYNTHIA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RODRIGUEZ | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | CYNTHIA | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 130 W BRANCH ST STE B | ||||||||
| Address2: | |||||||||
| City: | ARROYO GRANDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934206617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617170644 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2120 CIENAGA ST | ||||||||
| Address2: | |||||||||
| City: | OCEANO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934459016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059942101 | ||||||||
| FaxNumber: | 8059942197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 03/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 104100000X | 85326 | CA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.