Basic Information
| Provider Information | |||||||||
| NPI: | 1982142410 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JIMENEZ | ||||||||
| FirstName: | EDGAR | ||||||||
| MiddleName: | LEONEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1764 | ||||||||
| Address2: | |||||||||
| City: | CAMARILLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930111764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052845403 | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 RESERVOIR DR . | ||||||||
| Address2: | SUITE 204-A | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6198221800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2017 | ||||||||
| LastUpdateDate: | 03/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.